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

 
We decided that the Plan has to pay for laboratory services (87481, 87500, 87640, 87652 and 87798) provided 
on December 19, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that this entity or provider cannot be 
located. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial in this case, and 
this reason has not been supported with evidence and a relevant citation. The Plan states that they are unable to 
locate the provider, but does not provide any explanation as to why this is, nor did they include a copy of the 
original claim submitted. Without the original claim, we cannot verify if any submitted information is missing 
or inaccurate. The Plan has not substantiated their denial in this case. Therefore, we decided that the Plan has to 
pay for laboratory services (87481, 87500, 87640, 87652 and 87798) provided on December 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 lab services provided on October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection for the cervical or thoracic spine 
(64490) and facet joint injections for the lumbar or sacral spine (64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that incorrect information was submitted. 
You say that you advised your relief was 100% initially and was not less than 80% after that. You also say that 
the denial indicates you only had 65% relief. The Plan denied your request. The Plan says the facet joint 
injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation (RFA) of 
cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically 
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary 
diagnostic medical branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained 
relief of primary (index) pain. 
 
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 facet joint injections. Our reviewer says that the requested facet joint injections are not medically necessary. Our physician reviewer found the 
provided records in this case do not document 2 medically reasonable and necessary diagnostic MBBs, with 
each one providing a consistent minimum of 80% sustained relief of primary (index) pain. Therefore, the 
reviewer found that the requested facet joint injections are not medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection for the cervical or thoracic spine (64490) and facet joint 
injections for the lumbar or sacral spine (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel test billed for date of service April 14, 2023. 
 
You asked the Plan to pay for the billed services. You say that the records show the testing was performed. The 
Plan denied your request. The Plan says the testing is considered excessive. 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. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. In 
this case, the records do not show why the panel testing was needed above the standard of care testing. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the panel test billed for date of service April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulators (TENS) 
device monthly supplies coded as A4556, A4557 and A4630 provided July 7, 2022. 
 
You asked the Plan to pay for the TENS device supplies. You say that the TENS device supplies are not 
considered convenience items. They are medically necessary attachments that are essential for the use with the covered TENS unit.  The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, there is no proof of delivery in the records 
provided. Also, the TENS device was requested to treat the enrollee's diagnosis of chronic low back pain which 
is considered not medically necessary by Medicare. Therefore, we decided that the Plan does not have to pay 
for the transcutaneous electrical nerve stimulators (TENS) device monthly supplies coded as A4556, A4557 
and A4630 provided July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee's 
treatment. The Plan denied your request. The Plan says the documentation does not indicate that the enrollee 
has had a surgical resection. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested use of Keytruda is not medically necessary. Our physician reviewer found the record indicates that 
the enrollee has a stage II squamous Non-Small Cell Lung Cancer and has received radiation therapy and a regimen of adjuvant chemotherapy that did not include the requested drug. The Food and Drug Administration 
has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
26, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.   
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 14, 2023. 
 You asked the Plan to pay for the billed services. You say that a proprietary form was provided. The Plan 
denied your request. The Plan says they are unable to determine if the criteria was met. 
 
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. In this case, there are insufficient medical records to show the testing 
was indicated for the enrollees condition. Based on this information, we decided that the Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed 
for date of service February 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87081, 87186, 87502, 87581, 87634, 
87651, 87798, U0003 and U0005) billed for date of service November 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services (87081, 87186, 87502, 87581, 87634, 87651, 87798, U0003 and U0005) billed for date of 
service November 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 24, 2022, 
to January 12, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 24, 2022, to 
January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. 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 a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds, but does not exceed 600 pounds. 
 
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 heavy duty extra wide hospital bed. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found as of June 28, 
2023, the enrollee's weight was reported as 265 pounds. Medical records documenting a more recent weight 
measurement are not available to this reviewer. 
 
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 heavy duty extra wide hospital bed have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy duty extra wide hospital bed (E0303).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 10, 2023, to April 14, 2023. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that the claim should not 
have denied and the medical records support the ambulance services were medically necessary. The Plan 
denied your request. The Plan says our policy covers nonemergency ambulance transportation when it is the 
only way to safely and adequately transport a member, or if other means of transporting a member are unsafe 
due to a medical condition. This claim does not meet these requirements. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance transport services were not medically necessary.  Our physician reviewer found the transportation via ambulance to/from various appointments was not 
medically necessary. The enrollee was not bedbound, as evidenced by the ability to sit in a wheelchair and a 
dialysis chair. The enrollee did not require the expertise of trained personnel or the equipment available only on 
an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means 
(stretcher van, wheelchair van, private car, taxi) without endangering 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 the ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 10, 2023, to April 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heat pad billed for dates of service November 21, 2022, 
to December 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical literature shows the efficacy of 
treatment. The Plan denied your request. The Plan says the services are 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 looked at the file, and Medicare rules. We find that the water circulating heat pad with pump, billed with 
code E0217, is not reasonable and necessary. 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 heat pad billed for dates of service November 21, 2022, to December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on February 24, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing codes 86003 and 86008 billed for date of service 
March 24, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary to treat the 
enrollee. The Plan denied your request. The Plan says the testing is non-covered for this enrollee. 
 
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. In this case, there are insufficient medical records that show the need 
for the testing was based on findings during a complete history and physical exam. Based on this information, 
we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does 
not have to pay for lab testing codes 86003 and 86008 billed for date of service March 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 15 
2022, through August 20, 2022, at the Diagnosis Related Group (DRG) 189 originally billed. 
 
You asked the Plan to pay for the acute inpatient hospital care at the DRG originally billed. You say that you 
are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says 
the clinical evidence provided does not support the diagnosis code indicated.  
 
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 diagnosis code J96.01 as defined by acute 
respiratory failure with hypoxia. 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 the acute inpatient hospital care provided 
was not correctly billed. Our physician reviewer found that the enrollee presented with hypoxia, following a 
recent admission for rapid-rate atrial fibrillation. The enrollee was found to have a mild increase in size of 
previously identified pleural effusions. There is no evidence that the enrollee had respiratory failure. As such, 
the billing of code J96.01 is not 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 the acute inpatient hospital care provided from August 15 2022, through August 20, 2022, at the Diagnosis 
Related Group (DRG) 189 originally billed.