Persius/hicric huggingface dataset:
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 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. 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 enrollee was admitted to the hospital with acute hypoxic respiratory failure and 
pulmonary edema in the setting of myocardial infarction. He had a complicated course and requires antibiotics 
prior to further intervention. He continues to receive acute care services and these have not been denied.  The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The LTACH services are not reasonable or medically necessary at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart Implantable Pulse Generator. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is whether implantation of the cardiac contractility modulation system (CCM) system in this 
patient is medically necessary for the treatment of CHF which has been deemed refractory to optimal medical 
therapy. An exhaustive review of the current medical literature pertaining to the CCM system confirms 
multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of 
CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, 
with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. 
While the clinical studies led to FDA approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Optimizer Smart Implantable Pulse Generator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman G3R interspinous device to L3-4. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Minuteman interspinous device in the setting 
of lumbar spinal stenosis have not been demonstrated in the peer-reviewed literature. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Minuteman G3R interspinous device to L3-4.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest and 
abdomen/pelvis. 
 
You asked the Plan to pre-approve CT scans of the chest and abdomen/pelvis. You say that these CT scans are 
medically necessary. The Plan denied your request. The Plan says CT scans of the chest and abdomen/pelvis 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve CT scans of the chest and 
abdomen/pelvis. Our reviewer says that CT scans of the chest and abdomen/pelvis are not medically necessary. 
Our physician reviewer found the medical records indicate non-specified blood work has been ordered to look 
for hypercoagulopathy.  No lab results are in the chart.  The patient's stroke was in July of 2021 and no other 
imaging has been provided. The medical necessity of the requested CT scans has not been established in the 
records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the chest and abdomen/pelvis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest and 
abdomen/pelvis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 13, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this was a medically necessary test which was 
provided for a covered indication. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of F1CDx testing have 
not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) 
(0037U) testing provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jak2 (Janus Kinase 2) Gene Analysis, P.Val617Phe 
(V617F) Variant (81270) and JAK2 (Janus kinase 2) targeted sequence analysis (81279). 
 
You asked the Plan to pre-approve genetic testing. You say that the testing is medically necessary. The Plan 
denied your request. The Plan says the provider has requested JAK2 and JAK2 V617 testing to evaluate for 
polycythemia vera. Medicare states that BCR-ABL testing must be performed and negative prior to proceeding 
to JAK2 testing. There is no documentation to show this enrollee has had BCR-ABL testing performed. 
 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 laboratory testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the local coverage determination enumerates the conditions and limitations of 
coverage for the requested service. In this case, the record indicates that the enrollee has erythrocytosis. The 
record does not document that the enrollee has testing results indicating that he is BCR-ABL negative. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Jak2 (Janus Kinase 2) Gene Analysis, P.Val617Phe (V617F) Variant (81270) and JAK2 
(Janus kinase 2) targeted sequence analysis (81279).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 11, 2021, to 
March 12, 2021. 
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. The Plan denied your request. The Plan says that the documentation did not contain the visit notes 
for billed visits on the claim. All visits were also denied for no documentation as there was no evidence to 
support preparing of clinical notes occurred. 
 
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 home health services have been met. 
Specifically, the documentation did not contain the visit notes for billed visits on the claim. All visits were also 
denied for no documentation as there was no evidence to support preparing of clinical notes occurred. 
Therefore, we decided that the Plan does not have to pay for home health services provided from  
February 11, 2021, to March 12, 2021.
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 LTACH level of care is 
recommended for pulmonary rehabilitation and continued physical and occupational therapy. You say that the 
enrollee will benefit from the mobility program at the LTACH allowing them to return home. The Plan denied 
your request. The Plan says the current setting is safe, effective, and appropriate for the enrollee's care. 
 
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 
the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee appears to be improving and should only require short-term additional acute 
care services that can safely be performed at the current facility. Transfer to the LTACH would not be 
clinically advantageous and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
November 14, 2021, to November 18, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the determination to remove secondary diagnosis code J96.21 (Acute and chronic respiratory failure with hypoxia) is upheld consistent with the 
medical record documentation received for review. 
 
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 . 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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
review has determined that the records do not support the use of secondary diagnosis code J96.21 - acute and 
chronic respiratory failure with hypoxia - in this case. There was no clinical documentation of respiratory 
failure with hypoxia.  
 
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 inpatient hospital services provided to the enrollee from November 14, 2021, to November 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88342-TC, 88360-TC) provided on May 
5, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The services at issue were provided to a hospital outpatient but were 
billed with the TC modifier. Based on this information, we decided that Medicare rules for coverage of 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
services (88342-TC, 88360-TC) provided on May 5, 2022.
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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 that there are no identifiable skilled nursing service needs. The enrollee does not 
require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-contrast CT of the heart with calcium scoring 
(code 75571). 
 
You asked the Plan to pre-approve a non-contrast CT of the heart with calcium scoring. You say that a non-
contrast CT of the heart with calcium scoring is medically necessary. The Plan denied your request. The Plan 
says a non-contrast CT of the heart with calcium scoring is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a non-contrast CT of the heart with 
calcium scoring. Our reviewer says that a non-contrast CT of the heart with calcium scoring is not medically 
necessary. Our physician reviewer found the enrollee is a 70-year-old male with elevated cholesterol, total 
cholesterol 211 and low-density lipoprotein (LDL) 156.  The enrollee has left arm pain thought to be skeletal in 
origin. There are no cardiac symptoms. The enrollee has Type II diabetes. There is no calculation of lifetime 
risk of coronary artery disease is in the records. Medicare does not cover screening for coronary calcium unless 
there are cardiac symptoms or there is a calculated lifetime risk of coronary disease of 9-19%. No such 
calculation is in the records to provide medical necessity for this test in an asymptomatic patient. 
 
 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 non-contrast CT of the heart with calcium scoring have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a non-contrast CT of the heart with calcium 
scoring (code 75571).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. 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 Medicare may pay for unlabeled uses for FDA-
approved 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 
services are not medically necessary. Our physician reviewer found Keytruda (pembrolizumab) is indicated for 
the treatment of patients with unresectable or metastatic, microsatellite instability-high (MSI-H) or mismatch 
repair deficient (dMMR) colorectal cancer as determined by an FDA-approved test. Provided records do not 
document that this enrollee has microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) 
colorectal cancer. The use of Keytruda for the treatment of colorectal cancer without evidence of microsatellite 
instability-high (MSI-H) or mismatch repair deficient (dMMR) status is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. 
 
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 Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99490 and 99439 billed for date of service 
February 15, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 99490 and 99439 were provided while the enrollee was receiving inpatient hospital 
services. Payment for this service would have been included under the facility claim. Payment for this service 
is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99490 and 99439 
billed for date of service February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (62323). 
 
You asked the Plan to pre-approve the repeat ESI. You say that the requested injection is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found there is no documentation of the degree 
and duration of pain relief from the epidural steroid injection provided on August 8, 2022. Therefore, the 
reviewer found that a repeat ESI is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (62323).