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

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on December 15, 2022.  
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the guidelines state that fungal infection of the nail can be verified 
by direct microscopic examination with potassium hydroxide, fungal culture of desquamated subungual 
material, or fungal stain of a nail clippings fixed in formalin.  
 
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 a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the current standard of care for investigation of onychomycosis in a toenail is to 
perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, and specific. 
It is unclear as to why this enrollee's toenail specimen required PCR testing when other less expensive and 
efficacious lab tests (KOH and fungal culture) are available. This testing 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 a fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on December 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 30, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not covered by Medicare or by the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services provided on 
March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness upgrade (E2313) 
specialty joystick handle for hand control interface, prefabricated (E2323) and electronic connection between 
wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics and specialty joystick. You say that you need this 
power wheelchair and all of its parts. Please reconsider and review all attached. The Plan denied your request. 
The Plan says the upgraded electronics and specialty joystick 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 upgraded electronics and specialty 
joystick. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has had a stroke but has adequate strength in 
right upper extremity. The upgraded electronics and specialty joystick are not medically necessary as the 
enrollee has adequate upper body strength to manage standard power drives. 
 
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 upgraded electronics and specialty joystick have not been met. Therefore, 
we decided that the Plan does not have to pre-approve expandable controller (E2377) harness upgrade (E2313) 
specialty joystick handle for hand control interface, prefabricated (E2323) and electronic connection between 
wheelchair controller and two or more power seating system motors (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months continued use of non-invasive ventilator 
(E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that you would like the medical records to be reviewed 
and the authorization to be reconsidered and approved. The Plan denied your request. The Plan says the request 
for continued use of a noninvasive ventilator does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records document that the home ventilator is being requested for use in a volume 
assured pressure support (IVAPS) mode which is a modality that could be provided by a bilevel positive airway 
pressure (BiPAP) device with average volume assured pressure support (AVAPS) and a back-up rate. The 
records do not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The records in 
this case do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as 
opposed to a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months continued use of non-invasive ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic brachytherapy services. 
 
You asked the Plan to pre-approve electronic brachytherapy services. You say that electronic brachytherapy 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says electronic 
brachytherapy services are experimental/investigational for the enrollee's condition. 
 
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 electronic brachytherapy services. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there are no compelling reasons offered for why electronic brachytherapy 
services would be needed over more standard approaches of radiation delivery. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electronic brachytherapy services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electronic brachytherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with single power 
option, power tilt, and accessories. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the submitted records do not support that 
you are at high risk for skin breakdown, have a history of pressure ulcers, or have had skin flap surgery. You 
are independent with stand-pivot transfers while using equipment. You are able to transfer independently and 
do not perform bladder self-catheterization. The criteria for coverage are not met and the requested Group 3 
PWC with power tilt and accessories 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Group 3 power wheelchair (PWC) with single power option, power tilt, and accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from July 30, 2022, to 
July 31, 2022. 
 You asked the Plan to pay for the inpatient hospitalization. The Plan denied your request. The Plan says the 
information now received does not support that criterion were met for inpatient hospitalization and the original 
denial is upheld. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the initial examination and workup revealing no serious acute process, it 
was not expected that the enrollee would have required hospital services that would have likely crossed 2 
midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from July 30, 2022, to July 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 24, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. 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 the pneumatic compression device provided on February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for April 19, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for April 
19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 for date of service 
March 9, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, and J1817. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 96365, 96366, 96521, and J1817 is not supported in the medical record. Specifically, 
the documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or 
continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea 
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. 
There is a more appropriate code to be billed for these services. Therefore, codes 96365 and 96366 cannot be 
verified. The documentation submitted did not include documentation of Refilling and maintenance of portable pump; 
therefore, code 96521 cannot be verified. The medical records indicate that Nova R was administered via 
intravenous treatment. There is a more appropriate code to be billed for this service. This means code J1817 
cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 96365, 96366, 96521, and 
J1817 have not been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, 
96521, and J1817 for date of service March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740 x 2) for tooth numbers 5 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. The Plan's rule for crown restorations says 
that your tooth must have a cavity or have a lot of damage from being broken and it can no longer be fixed with 
a filling. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the documentation provided does 
not meet the criteria for coverage for crown restorations. Teeth number's 5 and 12 do not appear to have 
significant coronal breakdown due to caries or fracture to warrant crown restorations. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740 x 2) for tooth numbers 5 and 12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 13, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. 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 the pneumatic compression device provided on March 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624, 33289).  
 
You asked the Plan to pre-approve a CardioMEMS device. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says there is no documentation that the enrollee is enrolled in a 
Category B Investigational Device Exemption trial.  
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (C2624, 33289).
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 you need more therapy because you are not where 
you need to be at this time. The Plan denied your request. The Plan says the Medicare criteria for medical 
necessity has not been met. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our 
reviewer also found that your care needs can be met at a lower level of 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 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (81455) provided June 14, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please review the attached documentation and 
reprocess your claim for payment.  The Plan denied your request. The Plan says that this service was not 
authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of Adenocarcinoma of the colon and 
prostate. Next Generation Sequencing (NGS) has dramatically improved the flexibility and outcomes of cancer 
research and clinical trials, providing highly sensitive and accurate high-throughput platforms for large-scale 
genomic testing. In contrast to whole-genome (WGS) or whole-exome sequencing (WES), targeted genomic 
sequencing (TS) focuses on a panel of genes or targets known to have strong associations with pathogenesis of 
disease and/or clinical relevance, offering greater sequencing depth with reduced costs and data burden. This 
allows targeted sequencing to identify low frequency variants in targeted regions with high confidence, thus 
suitable for profiling low-quality and fragmented clinical deoxyribonucleic acid (DNA) samples. As a result, 
TS has been widely used in clinical research and trials for patient stratification and the development of targeted 
therapeutics. The review has determined that the items/services at issue in this case are medically reasonable 
and 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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or disorder, 51 or 
greater genes (81455) provided June 14, 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 the laboratory and drug services related to end-stage renal 
disease (ESRD) provided on January 3, 2023 to January 19, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory and drug services. You say that you disagree with 
the denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing and injectable drugs. 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services and injectable 
drugs are not separately payable. No other payment for these services is allowed. Therefore, we decided that 
the Plan does not have to pay for the laboratory and drug services related to end-stage renal disease (ESRD) 
provided on January 3, 2023 to January 19, 2023.