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

 
We decided that the Plan does not have to pay for the genetic pathogen testing provided on June 8, 2023, billed 
with codes 87481-59, 87491-59, 87563-59, 87640-59, 87653-59, 87798-59, 87641-59, and 87500-59. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 pathogen testing 
provided on June 8, 2023, billed with codes 87481-59, 87491-59, 87563-59, 87640-59, 87653-59, 87798-59, 
87641-59, and 87500-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on January 16, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing panel provided on January 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 6, 2023. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. 
 
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 urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the clinical notes did not explain why PCR testing was needed beyond the standard 
urinalysis and culture as supported by current literature and guidelines. Current literature does not sufficiently 
support the general use of PCR testing over this standard. Therefore, without PCR showing evidence that it 
leads to improved outcomes, this request for such will be considered not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the urine PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on July 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups (D2950 x 2) for tooth numbers 5 and 7. 
 
You asked the Plan to pre-approve the dental services. You say that in 2021 your provider billed the Plan for 
services that you never received. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 29, 2021. Therefore, 
we decided that the Plan does not have to pre-approve core buildups (D2950 x 2) for tooth numbers 5 and 7.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from February 26, 2023, to March 27, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the continued SNF care should be covered 
under the Medicare Act. The Plan denied your request. The Plan says the continued SNF care was not 
medically necessary for the enrollee. 
 
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 pay for continued SNF care. Our reviewer says that 
the requested continued SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found the enrollee did not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued skilled nursing facility (SNF) care provided from February 26, 2023, to 
March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service June 22, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is 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 99215 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 high level of medical decision making.  
 
We find that CPT code 99215 is not supported in the medical record. The records show that a follow up visit 
was provided for gait issues. The records do not show that a high level of decision making was provided. 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 procedure code 99215 billed for date of service 
June 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's condition has stabilized, 
and they are ready for discharge from the acute care hospital. You also say the enrollee needs to be transferred 
to the LTACH to regain maximum/prior level of function to continue a multi-discipline approach of care. The 
Plan denied your request. The Plan says  the request for LTACH placement does not meet medical necessity.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. Given there are offered alternatives, admission to the LTACH is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay from February 7, 2023, through 
February 15, 2023. 
 You asked the Plan to pay for the inpatient hospital stay. You say that inpatient hospital stay should be paid 
because it was a separate admission and not related to the hospital stay from January 17, 2023, through January 
25, 2023. The Plan denied your request. The Plan says the inpatient hospital stay is denied because it was 
determined to be a readmission as evidenced by the same or closely related condition or procedure as the prior 
discharge from the hospital stay on January 17, 2023, through January 25, 2023, at the same hospital.  
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 stay. Our reviewer says 
that there is documentation that the readmission was medically necessary, but records support that the 
readmission resulted from a premature discharge from the same hospital. Our physician reviewer found records 
document the patient presented on February 7, 2023, with generalized weakness, dizziness, evidence of a right 
lower extremity stump infection, and sacral wound requiring treatment with intravenous antibiotics and wound 
care after discharge from the hospital on January 25, 2023, for the same or very similar problem. 
 
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 inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital stay from February 7, 2023, through February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCAssure BRCA 1 and BRCA 2 Comprehensive 
Analysis (81162). 
 
You asked the Plan to pay for the BRCAssure BRCA 1 and BRCA 2 Comprehensive Analysis. You say that 
this testing is medically necessary. The Plan denied your request. The Plan says the clinical questionnaire 
documents that the enrollee has no personal history of cancer. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the enrollee has any 
cancer diagnosis.  
 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 BRCAssure BRCA 1 and BRCA 2 
Comprehensive Analysis. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found that the enrollee has no personal history of cancer. No other medical documentation has been 
provided. From the documentation, it is unclear the medical necessity of needing to undergo BRCA 
comprehensive testing from the documentation that has been sent.  
 
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 BRCAssure BRCA 1 and BRCA 2 Comprehensive Analysis have not been 
met. Therefore, we decided that the Plan does not have to pay for the BRCAssure BRCA 1 and BRCA 2 
Comprehensive Analysis (81162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0481) provided on May 3, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the submitted medical records do not indicate a 
clear provider intent to order the number of drug classes billed. 
 
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 G0481 is drug testing, definitive, 8-14 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided do not 
include definitive/conclusive results for drugs from at least 8 drug classes, and the records do not support that 
the provider requested definitive testing of 8-14 drug classes based on the physician order and the screening results. Based on this information, we decided that Medicare rules for coverage of drug testing have not been 
met. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0481) provided on 
May 3, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to hold harmless for the ambulance oxygen and oxygen supplies (A0422) 
provided to you on April 1, 2023. 
 
You asked the Plan to hold harmless for the oxygen and supplies. The Plan denied your request. The Plan says 
that this is not a covered benefit. 
 
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 $250 copayment for each ambulance service. The rules 
also say that oxygen and other items and services provided as part of the transport are included in the FS base 
payment rate and are not separately payable. 
 
The records show that you were provided ambulance transportation and oxygen services during transport on 
April 1, 2023. The Plan applied a $250 copayment for the transportation services, which is not at issue in this 
case. As the oxygen and supplies are considered to be included in the base payment rate for ambulance 
transportation, you cannot be asked to pay more than a $250 copayment for the ambulance transportation, 
oxygen, and supplies. The plan has applied the wrong charges, as these supplies would be included in the 
copayment that already has already been paid. Therefore, we decided that the Plan has to hold harmless for the 
ambulance oxygen and oxygen supplies (A0422) provided to you on April 1, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH level of care is the only 
option for a safe discharge due to the need for hourly nursing and respiratory therapy care and daily physician 
management by several specialties. You would like reconsideration based on the records submitted. The Plan 
denied your request. The Plan says the enrollee does not meet the guidelines for LTACH services.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2023, to May 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2023, to May 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure. 
 
You asked the Plan to pre-approve intracept procedure. You say that it is medically necessary. The Plan denied 
your request. The Plan says it 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 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 (MR) showing, only modic changes (MC) 
without facet degenerative join disease or stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 You asked the Plan to pre-approve the injections. You say that the enrollee's lower back pain radiates to their 
right buttock. You say that the enrollee has failed conservative treatments. The Plan denied your request. The 
Plan says that facet joint injections are 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 the injections. Our reviewer says that 
facet joint injections are not medically necessary. Our physician reviewer found that the enrollee has 
radiculopathy and have received improvement with an epidural steroid injection. Therefore, the enrollee does 
not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of long-term acute 
care support for one-on-one ventilation weaning. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is unstable and only requires additional acute care that can be safely 
provided at the current facility until they are more stable. The enrollee does not require services at the LTACH 
that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.