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

 
We decided that the Plan has to pay for genetic testing (0242U) provided on December 25, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for services performed on or after March 16, 2018, 
the Centers for Medicare and Medicaid Services (CMS) has determined that Next Generation Sequencing 
(NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a 
Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating 
physician, and when 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 pay for the genetic testing. Our reviewer says that 
this test was medically necessary. Our physician reviewer found per National Comprehensive Cancer Network 
(NCCN) guidelines, a metastatic biopsy for histologic and molecular evaluation is recommended or treatment 
decision-making, including understanding eligibility for biomarker-directed treatments, genetic counseling, 
early use of platinum chemotherapy, and eligibility for clinical trials. The testing performed was medically 
necessary for this patient. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (0242U) provided on December 25, 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: 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 been receiving in home therapy for 
over a year and it is not working. The IRF services requested are medically necessary. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
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. Medical 
problems are stable. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pertussis vaccine. 
 
You asked the Plan to pre-approve the pertussis vaccine. You say that this vaccine is medically necessary. The 
Plan denied your request. The Plan says this is not covered under the Part B medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the pertussis 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the pertussis 
vaccine. Therefore, we decided that the Plan does not have to pre-approve a pertussis vaccine.  
 
Benefits for the pertussis vaccine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MRI have been met. Specifically, 
no medical records were submitted after multiple requests by the Plan. Therefore, we decided that the Plan does 
not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 25, 2023, billed with 
procedure code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim is billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. The claim is inappropriately reported with POS 22 as documentation 
shows that the enrolled was registered inpatient on this date of service. Based on this information, we decided 
that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on March 25, 2023, billed with procedure 
code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that the provider included a comparison chart to show 
that the enrollee would benefit from this request. The Plan denied your request. The Plan says this is not 
reasonable and necessary under Medicare guidelines. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the case records do not adequately demonstrate the need for IMRT using plausible dosimetric 
evidence (i.e. to what extent IMRT reduced the dose-volume exposure of critical normal tissues).  This is 
important in justifying the need for IMRT in clinical scenarios (such as this case) for which IMRT is not always standard. IMRT would be considered to be furnished in accordance with accepted standards or 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you require SNF services. The Plan denied your 
request. The Plan says you are near your baseline function and do not require SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The medical records support 
that services in the home with home health care or in a long-term care facility on a part time basis are 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel expenses incurred on July 24, 2023. 
 
You asked the Plan to pay for travel expenses. You say that this location is a shorter drive away than your 
assigned transplant location. The Plan denied your request. The Plan says these travel expenses were not 
incurred for travel to your assigned transplant hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which a Medicare 
Advantage (MA) plan provides transplant services at a more distant location, the MA plan must provide 
reasonable transportation for the enrollee and a companion to the distant facility, and provide reasonable accommodations for the enrollee and a companion while in the distant location for medical care. 
 
We looked at the file and Medicare rules. Although these travel expenses were for transplant related services, 
they were not incurred because the Plan provided transplant services at the location you traveled to. The Plan 
has arranged transplant care at a different location. Based on this information, we decided that Medicare rules 
for coverage of travel expenses have not been met. Therefore, we decided that the Plan does not have to pay for 
travel expenses incurred on July 24, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on September 8, 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 payment of CPT 99283 is more appropriate. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented to the 
emergency department with a report of no bowel movement for two weeks without pain, and taking laxatives 
with no effect. Vitals were stable, and the examination showed a soft non-distended and non-tender abdomen. 
The enrollee underwent and tolerated fecal disimpaction without complication, and was sent home. The 
provided documentation includes an appropriate history and examination; however, the documentation does not 
support a moderate level of medical decision-making to support CPT 99284. 
 
We looked at this coder'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 emergency room services (procedure code 99284) rendered on September 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a hypoglossal nerve neurostimulator 
(64582, C1767, C1787). 
 
You asked the Plan to pre-approve a hypoglossal nerve neurostimulator. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 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 pre-approve a hypoglossal nerve neurostimulator. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the enrollee has severe obstructive sleep apnea and a body mass index of 
38.9. 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 a hypoglossal nerve neurostimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of a hypoglossal nerve neurostimulator (64582, C1767, 
C1787).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve conduction studies to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve nerve conduction studies with an out-of-network provider. You say that you 
want the Plan to approve services with this provider. The Plan denied your request. The Plan says this provider 
is out-of-network. The services at issue are available in-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 
nerve conduction studies to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213-
25) rendered on May 22, 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 Current Procedural Terminology (CPT) code 99213-25 (1 unit) remains not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support the level of service as billed.  There is satisfactory documentation that the E/M service provided was 
distinct from the procedure performed the same day justifying the use of the 25 modifier. However, the 
documentation was insufficient to support the specific level of service billed. 
 
We looked at this coder'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 evaluation and management services (procedure code 99213-25) rendered on May 22, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on October 9, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be 
considered integral to, and therefore included in the payment for the injection service or other procedure 
provided. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
October 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dorzolamide-timolol. 
 
You asked the Plan to pre-approve the medication. 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 dorzolamide-timolol.   
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: 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's medical management and rehabilitation 
needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says based on the available information, admission to IRF is not reasonable and necessary, as the 
enrollee's condition does not meet the Medicare rules.  
 
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. The enrollee 
was admitted for anemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Koya nonpneumatic compression systems (K1024, 
K1033). 
 
You asked the Plan to pre-approve nonpneumatic compression systems. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are 
experimental/investigational. 
 
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 nonpneumatic compression systems. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested devices have not been shown to be superior to other standard 
treatments for the enrollee's medical condition. The studies do not indicate the Koya Dayspring Active Compression Garment System improves an individuals function or general health compared to standard 
treatment of lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nonpneumatic compression systems have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Koya nonpneumatic compression systems (K1024, K1033).