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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing rendered 
on December 21, 2022. 
 
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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the test panel is a single test with multiple components 
and is characterized by a single unit of service (UOS =1). 
 
We looked at the file and Medicare rules. The file shows that the testing was not billed as a single unit of 
service. 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 pay for the urine polymerase chain reaction (PCR) 
testing rendered on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided while in the Swiss 
Confederation on October 8, 2022. 
 
You asked the Plan to pay for air ambulance transport. You say that the enrollee did not have access to the 
needed care within Switzerland. The Plan denied your request. The Plan says the needed supporting 
documentation was not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 air ambulance transport have been met. 
Specifically, no medical records supporting this air ambulance transportation were submitted. The Plan 
requested supporting records but they were not submitted. Therefore, you have not shown that this service 
meets criteria for payment. Therefore, we decided that the Plan does not have to pay for air ambulance 
transportation provided while in the Swiss Confederation on October 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with volume-
assured pressure support (VAPS) capability and failure of such a device has not been documented. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you want this item because 
your current standard system limits you on travel. The Plan denied your request. The Plan says this item is not 
covered for travel. 
 
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 pre-approve a portable oxygen concentrator (E1392).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the 
current setting. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. 
 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic sleep study (95800). 
 
You asked the Plan to pre-approve a diagnostic sleep study. You say that a diagnostic sleep study is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a diagnostic sleep study 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 diagnostic sleep study. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has a known diagnosis of obstructive sleep apnea and has been on 
bi-level positive airway pressure (BiPAP) for 13 years. The enrollee is in need of a new device. There are 
currently no sleep-related symptoms, the enrollee's compliance with using the device is excellent, the Epworth 
sleepiness score is normal at 2, and the apnea-hypopnea index (AHI) is 1.2 on the device. Since the enrollee is 
doing well on BiPAP, there is no need for a new diagnostic sleep study. The enrollee should be provided with a 
new device. 
 
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 diagnostic sleep study have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a diagnostic sleep study (95800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2022, billed 
with codes 81406, 81405, and 81404. 
 
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 
December 6, 2022, billed with codes 81406, 81405, and 81404.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way (rotary wing) (A0431-SH-GZ) and rotary wing air mileage, per statute mile (A0436-SH-GZ) provided on 
September 17, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that you are requesting payment based upon 
ground rates. You state the enrollee suffered a stroke, which requires emergency ambulance transportation to 
the closest facility with neurosurgery services available. The Plan denied your request. The Plan says 
information provided at the time of the appeal does not support criteria for air ambulance transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our physician 
reviewer found the documentation does not support that the enrollee's condition was such that the time needed 
to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's 
survival or seriously endangered the enrollee's health. Furthermore, payment is made according to the level of 
medically necessary services actually furnished. That is, payment is based on the level of service furnished 
(provided they were medically necessary), not simply on the vehicle used. Even if a local government requires 
an Advanced Life Support (ALS) response for all calls, payment under the Fee Schedule (FS) is made only for 
the level of service furnished, and then only when the service is medically necessary. All claim line(s) items 
submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for ambulance service, conventional air services, transport, one way (rotary wing) 
(A0431-SH-GZ) and rotary wing air mileage, per statute mile (A0436-SH-GZ) provided on September 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical radiofrequency ablation (RFA), two levels. 
 
You asked the Plan to pre-approve cervical RFA. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says there is no treatment plan documented in the records for cervical RFA. The 
Plan also says that the requested injections are not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients after the patient has had at least two (2) medically reasonable and necessary diagnostic 
medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of 
primary (index) pain. 
 
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 cervical RFA. Our reviewer says that 
the requested cervical RFA are not medically necessary. Our physician reviewer found the records do not show 
that the previous cervical RFA performed on January 28, 2020, provided 50% improvement of pain for at least 
six (6) months or at least 50% consistent improvement in the ability to perform previously painful movements 
and activities of daily living (ADLs) as compared to baseline measurement using the same scale. Therefore, the 
reviewer found that the requested cervical RFA are 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 cervical RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical radiofrequency ablation (RFA), two levels.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 billed for December 1, 2022. 
 
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 separately paid. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. Billed procedure code A4930 has an OPPS status indicator of N and 
no separate payment. Therefore, we decided that the Plan does not have to pay for procedure code A4930 billed 
for December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says 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 facet joint injections. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has radiculopathy. The enrollee does not meet coverage criteria for facet joint 
injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair (K0001) and related supplies provided 
on December 16, 2022. 
 
You asked the Plan to pay for a standard wheelchair and related supplies. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the documentation 
requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided in this case. The document 
provided as proof of delivery is not for the billed date of service. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a standard wheelchair (K0001) and related supplies provided on December 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parenteral solution amino (B4189). 
 
You asked the Plan to pre-approve parenteral solution amino. You say that the enrollee needs this. The Plan 
denied your request. The Plan says the requested treatment is not covered for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that for parenteral nutrition to be considered reasonable 
and necessary, the beneficiary must have (a) a condition involving the small intestine and/or its exocrine glands 
which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a 
motility disorder and impairs the ability of nutrients to be transported through and absorbed by the 
gastrointestinal (GI) system. 
 
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 parenteral solution amino. Our reviewer 
says that the request for parenteral solution amino is not medically necessary. Our physician reviewer found the record indicates that the enrollee has unspecified severe protein calorie malnutrition in the setting of end stage 
renal disease. The record provided does not establish that the enrollee has a gastrointestinal disorder that 
impairs motility or nutrient absorption. Therefore, the reviewer found that the request for parenteral solution 
amino 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 parenteral solution amino have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parenteral solution amino (B4189).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barton's lift chair (E1036). 
 
You asked the Plan to pre-approve a Barton's lift chair. You say that this is medically necessary. The Plan 
denied your request. The Plan says criteria for coverage is not met. 
 
The Plan follows Medicare rules. Medicare rules say that a multi-positional patient transfer system can be 
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 a Barton's lift chair. Our reviewer says 
that you do not meet coverage criteria. Our physician reviewer found the documentation does not support that 
you require supine positioning for transfers.  
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 Barton's lift chair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Barton's lift chair (E1036).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36561, 76937, and 77001 billed for May 31, 
2022. 
 
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 procedure codes 36561, 76937, and 77001 are 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 36561 is insertion of tunneled centrally inserted central 
venous access device, with subcutaneous port; age 5 years or older. The definition of code 76937 is ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of 
selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent 
recording and reporting (List separately in addition to code for primary procedure). The definition of code 77001 is fluoroscopic guidance for central venous access device placement, replacement (catheter only or 
complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any 
necessary contrast injections through access site or catheter with related venography radiologic supervision and 
interpretation, and radiographic documentation of final catheter position) (List separately in addition to code 
for primary procedure). 
 
We find that CPT codes 36561, 76937, and 77001 are not supported in the medical record. Specifically, there is 
no documentation of insertion of tunneled centrally inserted central venous access device, with subcutaneous 
port, age 5 years or older to support code 36561. Given that the primary procedure code 36561 is not 
supported, add-on codes 76937 and 77001 are also not supported. 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 pay for procedure codes 36561, 76937, and 77001 billed for May 31, 2022.