Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health skilled nursing and home health 
aide visits. 
 You asked the Plan to pre-approve additional home health services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee uses a walker and has no ostomy. While seen by a nurse, there is no evidence that the enrollee required 
or received skilled nursing services (i.e., IVs, complex wound care, new ostomy, new tube feeds). The 
requested quantity of home health services is not supported. Therefore, the enrollee does not meet criteria for 
the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional home health skilled nursing and home health aide visits.
Appeal type: Lab
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 December 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. 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 
December 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transluminal peripheral atherectomy (0238T) provide 
from November 23, 2022, to November 24, 2022. 
 
You asked the Plan to pay for the transluminal peripheral atherectomy. You say that this procedure was 
medically necessary for the enrollee. The Plan denied your request. The Plan says this procedure 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 pay for the transluminal peripheral atherectomy. Our 
reviewer says that the transluminal peripheral atherectomy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the indications for treatment and procedural details are not 
included in the operative report that was provided. Therefore, the reviewer found that the procedure 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 the transluminal peripheral atherectomy have not been met. Therefore, we 
decided that the Plan does not have to pay for the transluminal peripheral atherectomy (0238T) provide from 
November 23, 2022, to November 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve an injection. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you have failed conservative treatment including 
NSAIDs, analgesics, steroids, ESI. The requested injection is excluded from coverage and considered 
experimental/ investigational due to lack of literature establishing clinical efficacy, safety, or the applicability 
to clinical practice. 
 
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 injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have low back pain and intervertebral disc degeneration at L3-L4 and L4-L5. You have 
failed conservative treatment including NSAIDs, analgesics, steroids, Epidural Steroid injections. This is 
considered experimental therapy. Therefore, the request is deemed not 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 injection have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, 
unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 13, 
2022, to November 23, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $335 copayment per day for days 1-6 for inpatient hospital stay. There is no limit to the number of 
days covered by the plan. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other 
types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the 
hospital with a doctor's order. The day before you are discharged is your last inpatient day. The provider billed 
in the amount of $60,539.40 and the plan payments/discounts is $59,379.40 for the services. $60,539.40 - 
$59,379.40 = $1,160. Therefore, results in the total cost sharing amount of $1,160. 
 
The enrollee has been asked to pay a $1,160 copayment for inpatient hospital stay. This item/service falls 
within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on November 13, 2022, to November 23, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 26, 2022.  
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with bill type 130. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider would use code 0 when it does not 
anticipate payment from the payer for the bill, but is informing the payer about a period of non-payable 
confinement or termination of care. 
 
We looked at the file and Medicare rules. In this case, the provider did not indicate why the bill type 130 was 
used to indicate no payment. Without explanation, the services cannot be paid in this case. 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 the ambulance services provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99223) provided on July 2, 2022. 
 
You asked the Plan to pay for initial hospital care (99223). You say that the physician documented a 
comprehensive history, a comprehensive examination and medical decision making of high complexity. You 
say that the coding of 99223 is supported by the medical records and the claim should be reconsidered. The 
Plan denied your request. The Plan says that the medical records submitted do not support a comprehensive 
history. 
 
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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit. 
 
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 initial hospital care (99223). Our reviewer says that the 
documentation supports procedure code 99223. Our reviewer found the documentation does contain a history 
of the present illness, past medical history, social history, allergy list, medication list and review of systems.  
As such, the history is considered comprehensive, and the denial is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital care (99223) have been met. Therefore, we decided that the Plan 
has to pay for initial hospital care (99223) provided on July 2, 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 ConfirmMDx testing (81551) provided on December 28, 
2022. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that this test was medically necessary and 
reasonable. The Plan denied your request. The Plan says the criteria for this test are not met as the ordering 
provider was not planning on a repeat biopsy at the time of the test. 
 
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 ConfirmMDx testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found ConfirmMDx Prostate is not considered a standard of care in determining the risk of prostate 
cancer in benign biopsies. Use is not supported by the National Comprehensive Cancer Network (NCCN) 
guidelines or medical literature. The service was not reasonable or 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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx testing (81551) provided on December 28, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 0117U billed for date of service November 7, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that procedure 
code 0117U is not a covered code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan denied services based on the guidelines provided in Local Coverage Article A58812. We find that this 
Article is not binding in this case. The rule does not have Medicare Part B jurisdiction in Kentucky, where the 
services were provided. The Plan offered no other rationale for their denial. The Plan has not made reasonable 
and diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for procedure code 0117U billed for date of service November 
7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro powered upper extremity range of motion assist 
device. 
 
You asked the Plan to pre-approve MyoPro. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested item 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 MyoPro. 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 left upper extremity paralysis since suffering a traumatic brain injury in 1985. 
The enrollee has tried physical and occupational therapy. The MyoPro Orthosis is not known to be effective, 
based on scientific evidence, professional standards and expert opinion, in improving health outcomes.  The MyoPro is not the standard of care for this patient's condition or in widespread use for this patient's 
condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis 
will improve the long-term outcomes for this patient. There is insufficient evidence in the literature that this 
device will increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MyoPro powered upper extremity range of motion assist device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 28, 2022, billed 
with codes 81225 (XS), 81226 (XS), 81227 (XS), 81230 (XS), 81231 (XS), 81232 (XS), 81240 (XS), 81241 
(XS), 81291 (XS), 81306 (XS), 81328 (XS), 81355 (XS), 81335 (XS),81401 (XS), 0031U (XS), 0032U(XS), 
0033U (XS), 81479 (GY), 81407 (XS), 81406 (XS), and 81238 (XS). 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
February 28, 2022, billed with codes 81225 (XS), 81226 (XS), 81227 (XS), 81230 (XS), 81231 (XS), 81232 
(XS), 81240 (XS), 81241 (XS), 81291 (XS), 81306 (XS), 81328 (XS), 81355 (XS), 81335 (XS),81401 (XS), 
0031U (XS), 0032U(XS), 0033U (XS), 81479 (GY), 81407 (XS), 81406 (XS), and 81238 (XS).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa.  
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Monovisc is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drug. The prescriber has indicated that the patient has an allergy to eggs and bird products, however 
plan preferred Monovisc is not sourced from avian products. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 does not require remaining 
in the short-term acute care hospital; however, their needs are far too complex for a skilled nursing facility 
level of care or an inpatient rehabilitation facility. You also say the enrollee cannot return home with their 
increased needs at this time. The Plan denied your request. The Plan says the LTACH services requested do not 
meet the requirements for approval.  
 
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 all medically necessary care is being provided in the current acute care setting.  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. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided on January 4, 2023.  
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that the DecisionDx-SCC test was medically 
necessary. The Plan denied your request. The Plan says the DecisionDx-SCC test is not medically necessary. 
 The Plan follows 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 DecisionDx-SCC test. Our reviewer says 
that the DecisionDx-SCC test is not considered medically necessary. Our physician reviewer found that based 
on the medical records provided there is no documentation that the DecisionDx-SCC test provided on  
January 4, 2023, at issue in this case meets all Medicare criteria for medically reasonable and necessary, safe 
and effective for the enrollee. The provided records in this case do not document any factors that indicate 
necessity and efficacy of the testing. The documentation supplied states that the test is intended for use in 
patients with one or more risk factors and has not been evaluated for use in locally recurrent disease. The 
provided records include no details with regard to these factors.  
 
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 DecisionDx-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx-SCC test provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 11, 2022.