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

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 31, 
2023, through June 1, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that you were admitted on May 31, 2023 for an elective sling procedure. You tolerated the 
procedure without complication and you were discharged home on June 1, 2023. There was no documentation 
provided indicating the medical necessity for inpatient level of care services for the elective procedure. You 
were stable for observation level of care services. The review has determined that the record did not show that 
at the time of the inpatient admission the admitting physician reasonably expected that your necessary hospital 
care (including earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from May 31, 2023, through June 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says records do not show that the enrollee has modic-type findings on the lumbar 
magnetic resonance imaging. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of back pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided on June 1, 2021. 
 
You asked the Plan to pay for inpatient services. You say that these services were pre-approved and should be 
paid at the full allowed rate. The Plan denied your request. The Plan says there is insufficient documentation to 
process this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 inpatient services have been met. 
Specifically, no itemized list of services was provided for review, and no medical records were submitted. 
Without proper documentation, the items/services provided cannot be verified. Therefore, we decided that the 
Plan does not have to pay for inpatient services provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PancraGen test provided on March 7, 2023.  
 
You asked the Plan to pay for the PancraGen test. You say that this service was medically necessary. The Plan 
denied your request. The Plan says there is currently not enough supporting literature to recommend this testing 
as 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 PancraGen test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that although commercially available, the role of the service in question in clinical decision 
making, including selecting treatment options, has not been adequately defined to qualify the study as standard-
of-care for the enrollee's circumstance. 
 
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 PancraGen test have not been met. Therefore, we decided that the Plan does 
not have to pay for the PancraGen test provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve genetic testing. You say that this testing is needed to make a comprehensive 
treatment plan for you. The Plan denied your request. The Plan says this provider is out-of-network with the 
Plan and the needed testing can be done within the Plan network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
genetic testing to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been 
met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the criteria for coverage for a fixed 
bridge replacing missing tooth #19 have not been met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a C2 - C3 epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the enrollee does meet the criteria 
and that the scan does show disc space narrowing. The Plan denied your request. The Plan says that the 
enrollee does not meet medical necessity criteria. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections may be covered under 
certain circumstances. 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 an epidural steroid injection. Our 
reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer 
found that the LCD criteria requires radiological image-based diagnostic testing supporting one of the 
following: Lumbar, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to 
disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis. This is not documented at the level requested or at adjacent levels. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a C2 - C3 epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided on May 25, 2022. 
 
You asked the Plan to pay for pathology services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathology services have not been met. Specifically, the records suggest that these services were 
rendered in an outpatient facility. Procedure code 88305 has a professional/technical component indicator of 1. 
This means that this code has a professional and technical component. This code has not been billed with the 
appropriate modifier to indicate that it is for the professional component. Payment for the technical component 
of this code is included in the payment to the facility and is the responsibility of the facility to any vendor. 
Therefore, we decided that the Plan does not have to pay for pathology services (88305) provided on May 25, 
2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for a specialist office visit. We decided that the Plan does 
not have to waive the cost share for a specialist office visit.  
 You asked the Plan to correct the cost share for a specialist office visit provided on February 15, 2023. You say 
that you disagree with the cost share. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to correct the cost share for a specialist office visit.  
 
The Plan follows Medicare rules. 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 enrollees must pay a 40% coinsurance for the 
specialist office visit. 
 
The plan says you must pay 40% of the allowed amount of $176.08 which is $70.43, however, you cannot be 
asked to pay more than a $30 copayment. 
 
 
We also decided that the Plan does not have to waive the cost share for a specialist office visit. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for a specialist office visit. Therefore, we decided that the Plan does not have to waive the cost 
share for a specialist office visit. 
 
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: Favorable

 
We decided that the Plan has to pay for the testing provided on November 29, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the claim was billed 
with a missing or invalid unique test identifier. 
 
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. The Plan argues that the claim was billed with a missing or invalid unique test 
identifier. However, the submitted documentation shows that the claim was billed with unique test identifier 
ZO1Q3. The Plan has not provided documentation showing that this unique test identifier is not billable for the 
testing provided in this case. Without supporting documentation, the Plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for the testing provided on November 29, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that this is 
medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the 
Optimizer Smart Implantable Pulse Generator device has 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 an Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found cardiac contractility modulation systems remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2022, billed 
with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81407, 81408, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be covered. 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 9, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81407, 
81408, and 81272.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) months continued use of a ventilator (E0466). 
 
You asked the Plan to pre-approve continued use of a ventilator. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the request for continued use of a 
ventilator is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 continued use of a ventilator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has severe 
COPD with a forced expiratory volume (FEV1) of 35% of predicted in 2018. The enrollee has had a home 
ventilator since January 2020. It is being used in the average volume-assured pressure support (AVAPS) mode, 
which can be provided with bilevel positive airway pressure (BiPAP). Compliance download covering May 20, 
to June 18, 2023, shows the device is being used for at least four hours/day on only 33% of days. Medicare 
does not cover a home ventilator when used at settings that can be provided with BiPAP. In addition, the 
enrollee is not using the device enough to be effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued use of a ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine (9) months continued use of a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466).  
 
You asked the Plan to pre-approve a ventilator for 9 months. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS 
and a back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a 
back-up rate. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87900. We decided that the Plan does not have to pay 
for procedure code 87652.   

You asked the Plan to pay for procedure codes 87900 and 87652 provided on December 12, 2022.. You say 
that the medical records support the billing of codes 87900 and 87652. The Plan says that the medical records 
do not support the billing of codes 87900 and 87652. 
 
We decided that the Plan has to pay for procedure code 87900.  
 
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 87900 is Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics. 
 
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 procedure code 87900. Our reviewer says 
that the medical records do support the use of procedure code 87900 as there was a test of susceptibility on the 
clean catch sample. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87900.  
 
We also decided that the Plan does not have to pay for procedure code 87652. 
 
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 87652 is Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, 
quantification. 
 
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 procedure code 87652. Our reviewer says 
that the records do not support the use of procedure code 87652 as this is included within the urinary tract 
infection panel and not separately payable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87652 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87652. 
 
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.