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

 
We decided that the Plan does not have to pay for BRCA1, BRCA2 gene analysis; full sequence analysis and 
full duplication/deletion analysis (81162) provided on February 7, 2023. 
 
You asked the Plan to pay for BRCA1, BRCA2 gene analysis. You say that this test is a covered benefit. The 
Plan denied your request. The Plan says this testing is not covered for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and 
are not covered. 
 
We looked at the file and Medicare rules. The test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Based on this information, we 
decided that Medicare rules for coverage of BRCA1, BRCA2 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pay for BRCA1, BRCA2 gene analysis; full sequence analysis and full 
duplication/deletion analysis (81162) provided on February 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF care received on skilled nursing facility (SNF) care 
provided from October 30, 2022, to November 27, 2022. 
 
You asked the Plan to pay for the SNF care received on  October 30, 2022, through November 27, 2022. You 
say that the services were medically necessary. The Plan denied your request. The Plan says there is no 
evidence that the enrollee received skilled nursing or rehab services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 the enrollee did have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and 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 pay for the SNF care received on skilled nursing facility (SNF) care provided from October 30, 2022, to 
November 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on 
November 29, 2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says the claim was not billed 
with the required modifier for a capped rental item. 
 
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 payment for CPT code E0986 is not supported in the medical record. Specifically, this is 
considered to be a capped rental item, which requires the use of modifier RR, KH, KI, or KJ, for payment to be 
considered. Based on this information, we decided that Medicare rules for coverage of the DME have not been 
met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) 
provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 22, 2022. 
 
You asked the Plan to pay for lab test. You say that this testing was medically necessary. The Plan denied your 
request. The Plan says this claim was not billed with the required DEX Z-Code or the appropriate Place of 
Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the POS code.  
 
We looked at the file and Medicare rules. The sample for this testing was taken in an office setting. Therefore, 
the Place of Service (POS) code 81  indicating an independent lab setting  is not appropriate for this claim. 
Based on this information, we decided that Medicare rules for coverage of lab test have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, periodontal scaling and root planing, and gingival irrigation services (D4341, D0150, D0210, D4921) provided on April 13, 2022.

You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree with the denial. The Plan denied your request. The Plan says your benefit for the comprehensive oral evaluation, intraoral x-ray, periodontal scaling and root planing has already been exhausted. Coverage for the gingival irrigation services denied correctly as they do not fall within your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. Coverage for the gingival irrigation services denied correctly as they do not fall within your dental benefits. The record shows your benefit for the comprehensive oral evaluation, intraoral x-ray, periodontal scaling and root planing exhausted on date of service November 22, 2021 (D4921, D0210) and November 23, 2021 (D4341). Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, periodontal scaling and root planing, and gingival irrigation services (D4341, D0150, D0210, D4921) provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87641, 87481, 87150, 87653) provided on 
December 6, 2022. 
 You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable. 
 
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 codes 87641, 87481, 87150, & 87653 are not supported in the medical record. Specifically, 
codes 87641, 87841, & 87653  are included in code 87801 which was also billed. Code 87150 is included in 
code 87500 which was also billed. Records do no show that these are separate and distinct services. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87641, 87481, 87150, 87653) provided on 
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provide on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 Plan's 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 July 24, 2020. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provide on July 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on November 9, 
2022. 
 
You asked the Plan to pay for subsequent hospital care (99232). The Plan denied your request. The Plan says 
procedure code 99232 is not supported. 
  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 subsequent hospital care (99232) have 
been met. Specifically, medical records for the date of service at issue were not submitted to verify the service 
billed. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided 
on November 9, 2022.
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 only need inpatient rehabilitation for about five 
days and three hours a day. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
enrollee does not meet criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is 
Food & Drug Administration (FDA) approved for the enrollee's condition if there is no EGFR or ALK gene. 
The Keynote-042 trial supports this use. The enrollee needs EGFR and ALK gene testing to make sure there are no genomic aberrations of these genes prior to using Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Keytruda.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy, electrical stimulation, vasopneumatic 
device therapy, and subcutaneous injection services provided on February 1, 2023. 
 
You asked the Plan to pay for the physical therapy, electrical stimulation, vasopneumatic device therapy, and 
subcutaneous injection services. You say that you would like this claim to be reprocessed and paid. The Plan 
denied your request. The Plan says these services do not meet the requirements for approval. 
 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 physical therapy, electrical stimulation, 
vasopneumatic device therapy, and subcutaneous injection services. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal objective lab studies indicating a vitamin deficiency and the 
documentation does not support that the pharmaceutical blend injected is safe and effective for the patient. 
There are no objective findings that indicate this enrollee required electrical stimulation to increase blood flow, 
and this treatment is not supported for multiple neuropathies or peripheral polyneuropathy from an underlying 
disease. Our reviewer found that there is no evidence of edema, lymphedema or condition that required a 
vasopneumatic device. Our physician reviewer also found that the documentation does not support that the 
enrollee required skilled therapy services as the exercises performed were not of a complex nature that required 
a qualified clinician to oversee them. 
 
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 physical therapy, electrical stimulation, vasopneumatic device therapy, and 
subcutaneous injection services have not been met. Therefore, we decided that the Plan does not have to pay 
for the physical therapy, electrical stimulation, vasopneumatic device therapy, and subcutaneous injection 
services provided on February 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation codes A0431-GZ and A0436-GZ billed for 
date of service November 21, 2022. 
 You asked the Plan to pay for the billed services. You say that the enrollee required emergent transfer to the 
closest facility. The Plan denied your request. The Plan says the services are not covered with the billed 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. Claim lines submitted with the GZ modifier is automatically denied. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for transportation codes A0431-GZ and A0436-GZ 
billed for date of service November 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 70450-26-XU billed for date of service January 8, 
2023. 
 
You asked the Plan to pay for code 70450-26-XU. You say that code 70450 was denied for bundling 
inappropriately because you appended the XU modifier. The Plan denied your request. The Plan says the use of 
the XU modifier is not supported by the medical record. The records only indicates that the interpretation and 
report of the computed tomographic angiography (CTA) of the head and neck with contrast was performed. 
 
The Plan follows Medicare rules. Medicare rules say that modifier XU may be used to bypass a National 
Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) as long as the proper criteria for use of the 
modifier is met. Medical documentation must support the use of the modifier. The XU modifier is used to 
indicate Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap 
usual components of the main service."  
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 code 70450-26-XU. Our reviewer says that 
the use of the XI modifier to allow for separate payment of code 70450-26 is not supported by the medical 
records. Our physician reviewer found when reporting a computed tomography (CT) scan before CTA on the 
same visit with no new findings, code 70452 is included in CPT 70496.  In this case, documentation does not 
include documentation to support the modifier billed, as well as new findings.  Therefore, this procedure code 
and modifier cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 70450-26-XU have not been met. Therefore, we decided that the Plan does 
not have to pay for code 70450-26-XU billed for date of service January 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from September 9, 
2022, to September 15, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis was supported for this admission. The Plan denied your request. The Plan says sufficient 
documentation was not found to validate the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9, defined as sepsis, 
unspecified organism. 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 
services at the DRG originally billed. Our physician reviewer found that the enrollee presented with subacute 
cough and weakness. She was determined to have pneumonia and was admitted due to its prolonged course and 
her immunocompromised state. There is no evidence that the enrollee had hypotension, hypoperfusion or acute 
organ failure. As such, a diagnosis of sepsis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided from September 9, 2022, to September 15, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic (J3590). 
 
You asked the Plan to pre-approve Ozempic. You say that Ozempic has been added for better hemoglobin A1C 
control. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic (J3590).  
 
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.