Persius/hicric huggingface dataset:
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 medical records provided support the need for 
the requested IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about the enrollee's condition, they do not meet all of the factors.  
 
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 is medically stable with no acuity and does not need physical medicine 
and rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation skilled 
nursing needs identified or documented. At the current functional level, the enrollee needs routine physical 
therapy and occupational therapy and does not need specialized intensive therapies consisting of at least 3 
hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. The document 
does not support necessity for admission to an IRF. The IRF admission is not necessary or reasonable. With no 
medical complexity, and no rehabilitation nursing needs the enrollee does not require an IRF stay. The 
enrollee's rehabilitation needs can be provided in an alternate and low intensity setting such as in a skilled 
nursing facility or continued services at the assisted living facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) device 
(A4239) provided on June 27, 2023. 
 
You asked the Plan to pay for CGM supplies. You say that you have reported the services at issue correctly. 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the provided medical records do not discuss a CGM or related supplies. Therefore, we 
decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) device 
(A4239) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve D2740 for tooth #27. We decided that the Plan does not have to 
pre-approve D2740 for tooth #22 and core build-ups.  
 
You asked the Plan to pre-approve a crown (D2740) for teeth #22 and #27, and a core build-up (D2950). You 
say that this dental work is medically necessary. The Plan says that these services have been processed 
correctly. 
 We decided that the Plan has to pre-approve D2740 for tooth #27.  
 
Our doctor found that D2740 for tooth #27 are medically reasonable and necessary due to the size of the decay 
noted on the x-ray. Therefore, we decided that the Plan has to pre-approve D2740 for tooth #27.  
 
We also decided that the Plan does not have to pre-approve D2740 for tooth #22 or D2950. 
 
Our doctor found that more information is required such as a photo of tooth #22 to determine whether these 
procedures are necessary. D2950 are not covered benefits. Therefore, we decided that the Plan does not have to 
pre-approve D2740 for tooth #22 or D2950. 
 
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 laboratory services (procedure codes 87481, 87640, 87641, 
87651, 87798) rendered on July 31, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
provider reported modifier 59 to bypass the edits between the codes. However, the laboratory report does not 
support the infectious agent detection as separate and distinct, deserving separate payment. Additionally, in terms of CPT 87798, the laboratory report does not specify the tests that were performed for this "not otherwise 
specified" code. 
 
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 pay for laboratory services (procedure codes 87481, 87640, 87641, 87651, 87798) rendered on July 31, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 30, 2023. 
 
You asked the Plan to pay for the physical therapy services. You say that you are requesting reconsideration of 
the denied claim. 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 physical therapy 
services provided on June 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 for date of service May 22, 2023. 
 
You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service at issue was not billed with the required modifier to allow 
separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 10060 
provided on the same date of service. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 
for date of service May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal laboratory test (81479) provided on 
September 10, 2023. 
 
You asked the Plan to pay for the Guardant Reveal test. You say that the service was billed correctly. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the Guardant Reveal 
test have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant Reveal 
laboratory test (81479) provided on September 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA Molecular Signature testing (81479) provided 
July 24, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that please find appeal information that describes 
the medical necessity of the PrismRA test to inform consideration of payment.  The Plan denied your request. The Plan says at the time of the date of service, the DEX Diagnostics Exchange Registry showed that PrismRA 
was non-covered after MolDX review.  
 
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 laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PrismRA, Scipher Medicine, Waltham, MA, is a test to predict response to Tumor Necrosis 
Factor inhibitor (TNFi) therapy. The molecular signature test includes RNA sequencing and gene expression 
data to determine if an individual is unlikely to respond to TNFi therapy. The current version of the American 
College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis does not address the use of 
molecular signature testing. Molecular signature testing offers the potential to improve treatment response by 
avoiding TNFi therapy when an individual is predicted to be a non-responder. Additional peer-reviewed 
published studies are warranted, including studies with diverse populations, validation of responders versus 
non-responders, and the ability of the test to contribute to the improvement of net health outcomes of 
individuals with RA. The ACR provides no guidance regarding molecular signature testing. The integration of 
this test within standardized endorsed treatment guidelines is needed to demonstrate clinical utility. Molecular 
signature testing is being considered for other indications, such as ulcerative colitis, Crohn's disease, among 
others, however there is no published literature for indications other than RA. The review indicates that the 
medical records provided do not show that the test meets the medically necessary requirements for Medicare 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the PrismRA Molecular Signature testing (81479) provided July 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
September 09, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you had no choice 
other than to go to the emergency room. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $115 
copayment for emergency care. 
 
You have been asked to pay a $115 copayment for the emergency room services. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room 
services provided on September 09, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reimburse you for  the dialysis services provide June 24, 2023, to June 29, 
2023. 
 
You asked the Plan to reimburse you for  the dialysis services. You say that you were not out of the country, 
and you should be reimbursed. The Plan denied your request. The Plan says that routine dialysis on a cruise 
ship, while at sea outside of the United States, is not covered. 
 
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract 
says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal 
dialysis, and pre-approved care. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan has not substantiated their reason to deny by showing that 
the services were actually received outside of the U.S. There is no information in the case file on where the 
dialysis actually took place and if this cruise actually took place in the U.S., or outside of the U.S. Therefore, 
we decided that the Plan has to reimburse you for  the dialysis services provide June 24, 2023, to June 29, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided August 22, 2023. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided 
August 22, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine 
(72146). 
 
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 an MRI of the thoracic spine. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a history 
including underlying stenosis, recent percutaneous injections and a recent fall with thoracic dermatome 
physical findings to provide a valid indication for a thoracic spine MRI. 
 
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 MRI of the thoracic spine have been met. Therefore, we decided that the 
Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine (72146).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95938 and 95861 billed for date of service 
July 28, 2023. 
 
You asked the Plan to pay for procedure code(s) 95938 and 95861. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95938 and 95861. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95938 and 
95861. Based on this information, we decided that Medicare rules for coverage of procedure code 95938 and 
95861 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
95938 and 95861 billed for date of service July 28, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on September 22, 
2023. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that that you dont think that this 
simple 10 minute procedure with no anesthesia should carry the same copayment as the actual surgery that 
involved multiple departments at the hospital that you had prior to this procedure. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $370 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $370 copayment for the endoscopy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the endoscopy provided on September 22, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder endoscopy provided on 
September 7, 2023. 
 
You asked the Plan to waive the copayment for bladder endoscopy. You say that in the past your copayment 
for the same service has been $30. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 
copayment for bladder endoscopy in an ambulatory surgical center.  
 
You have been asked to pay $250 copayment for bladder endoscopy. This item/service falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a bladder endoscopy 
provided on September 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 26, 2023 
 
You asked the Plan to pay for the genetic testing billed. 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 
June 26, 2023