Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (CPT code 0037U) 
provided on June 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be processed. The Plan 
denied your request. The Plan says the results document no reportable alterations with companion diagnostic 
(CDx) claims and the claim denied due to not meeting Medicare LCD criteria. 
 
 
 
 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The available language in 
the current HIPAA compliant code sets used to describe the pathology and laboratory categories and the tests 
included in those categories are not specific to the actual test results provided, all MDT services must include 
an identifier as additional claim documentation. Test providers must receive an identifier specific to the 
applicable test and submit the test assigned identifier with the claim for reimbursement. The assigned identifier 
will provide a crosswalk between the tests associated detail information on file and the submitted claim detail 
line(s) required to adjudicate each tests claim. The unique identifier limits the need to submit the required 
additional information about the test on each claim. The claim did not contain a Dex-Z Code unique identifier 
required by Medicare. Additionally, per Medicare Claims Processing Manual Chapter 16 - Laboratory Services 
the service provided is not supported as the DOS of the test/service must be the date the specimen was 
collected. Specimen Collected June 1, 2022. Specimen Received June 8, 2022. Test Results June 15, 2022. 
Therefore, the claim should remain denied. Therefore, we decided that the Plan does not have to pay for the 
targeted genomic sequence analysis (CPT code 0037U) provided on June 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) services 
coded 33361 provided on May 13, 2022. 
 
You asked the Plan to pay for the transcatheter aortic valve replacement (TAVR) services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that TAVR is covered for uses that are not expressly 
listed as an FDA-approved indication when performed within a clinical study. The clinical trial number must be 
submitted on the claim.  
 
We looked at the file and Medicare rules. Review of the file shows that the clinical trial number was not 
provided on the claim. Based on this information, we decided that Medicare rules for coverage of the 
transcatheter aortic valve replacement (TAVR) services have not been met. Therefore, we decided that the Plan does not have to pay for the transcatheter aortic valve replacement (TAVR) services coded 33361 provided on 
May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT.) 
 
You asked the Plan to pre-approve PBRT. You say that the records provided support the need for PBRT. The 
Plan denied your request. The Plan says proton radiation has not been proven to yield superior clinical 
outcomes in the enrollee's situation. The Plan says that the enrollee did not supply a proton/photon plan 
comparison showing that intensity-modulated radiation therapy cannot provide adequate safety/precision. The 
Plan says that the enrollee has not received prior radiation to the pelvic region. 
 
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 PBRT. Our reviewer says that PBRT is 
not considered medically reasonable and necessary in this case. Our physician reviewer found both the 
National Comprehensive Cancer Network (NCCN) and the American Society for Radiation Oncology 
(ASTRO) guidelines recommend against the use of proton therapy to treat prostate cancer. PBRT would exceed 
the enrollee's needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT.)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (CPT code 30999). 
 
You asked the Plan to pre-approve the procedure. You say that you believe this procedure will provide a 
significant solution to your nasal breathing difficulty. The Plan denied your request. The Plan says the Vivaer 
procedure is experimental and investigational and not a covered benefit. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient literature to support the safety and efficacy of the requested service for your 
specific clinical condition. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the VivAer procedure (CPT code 30999).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy or excision of lymph node(s); open, deep axillary 
node(s) (CPT code 38525-AS, LT) and intraoperative identification (eg, mapping) of sentinel lymph node(s) 
includes injection of non-radioactive dye, when performed (38900-AS, LT) provided on February 9, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be processed. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. As the claim was billed with CPT 
code which is not valid for assistant at surgery services; we find that Medicare rule for payment of this claim 
has not been met. As Type I CPT Add-On code 38900-AS, LT was billed with primary code 38525-AS, LT 
which was denied, we find that Medicare rule for payment for CPT codes 38900 has not been met. Therefore, 
we decided that the Plan does not have to pay for the biopsy or excision of lymph node(s); open, deep axillary 
node(s) (CPT code 38525-AS, LT) and intraoperative identification (eg, mapping) of sentinel lymph node(s) 
includes injection of non-radioactive dye, when performed (38900-AS, LT) provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (breast), mRNA, gene expression profiling by 
real-time RT-PCR of 11 genes (CPT code 81518) provided on November 18, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be processed. The Plan 
denied your request. The Plan says the claim denied due to not meeting Medicare LCD criteria. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. The available language in 
the current HIPAA compliant code sets used to describe the pathology and laboratory categories and the tests 
included in those categories are not specific to the actual test results provided, all MDT services must include 
an identifier as additional claim documentation. Test providers must receive an identifier specific to the 
applicable test and submit the test assigned identifier with the claim for reimbursement. The assigned identifier 
will provide a crosswalk between the tests associated detail information on file and the submitted claim detail line(s) required to adjudicate each tests claim. The unique identifier limits the need to submit the required 
additional information about the test on each claim. The claim did not contain a Dex-Z Code unique identifier 
required by Medicare. Additionally, per Medicare Claims Processing Manual Chapter 16 - Laboratory Services 
the service provided is not supported as the DOS of the test/service must be the date the specimen was 
collected. Specimen Collected February 16, 2015. Specimen Received November 12, 2021. Test Results 
November 18, 2021. Therefore, the claim should remain denied. Therefore, we decided that the Plan does not 
have to pay for the oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes 
(CPT code 81518) provided on November 18, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 3, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on September 17, 2021.
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 it is critical that the enrollee be 
transferred to an LTACH verses a LLOC or remaining in the hospital as his condition has stabilized and will 
require a multi-disciplinary approach for an extended period of time. The Plan denied your request. The Plan 
says the enrollee is currently unstable for transfer to an LTACH and is receiving appropriate in-patient acute 
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 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more stable 
and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not 
already available at the current facility. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee (BK), ultra-
light material (titanium, carbon 
fiber or equal) (L5940). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested prosthetic component, under HCPCS code L5940, exceeds the enrollee's's 
needs and cannot be covered under the Medicare criteria for being reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that you have had a below the knee amputation that would 
necessitate authorization for the requested prosthesis. 
 
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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee (BK), ultra-light material (titanium, carbon 
fiber or equal) (L5940).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and guided tissue 
regeneration (D4266) for tooth #15. 
 
You asked the Plan to pre-approve a bone replacement graft and guided tissue regeneration. You say that tooth 
#15 has a large existing amalgam with leaking margins. You say there is recurrent gross decay encroaching 
into the pulpal space. The Plan denied your request. The Plan says this service is not covered by the Plan's 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D7953) and guided tissue regeneration (D4266) for tooth #15.
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 the enrollee needs this care. The Plan denied your 
request. The Plan says SNF care 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the Barostim Neo system was approved 
by the Food and Drug Administration (FDA) in 2019 for use in patients with refractory heart failure who 
remain symptomatic despite treatment with guideline-directed medical therapy, are NYHA Class III, have an 
ejection fraction less than 35 percent, and are not candidates for bi-ventricular pacing. There remains an 
absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value 
of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be 
considered medically reasonable and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Barostim Neo system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says according to the 
available records you do not meet all the required Medicare criteria for an admission to an inpatient 
rehabilitation facility. Skilled therapies at home or at a skilled nursing facility may be approved upon request. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for endocarditis after mitral valve surgery. Medical problems are 
stable. There are no complex nursing or rehabilitation needs.  While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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 IRF admission and services.