Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96372, 96375, and A4649 
billed for date of service October 23, 2022. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96372, 96375, and A4649. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the codes are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 5 for CPT codes 96365, 96366, 96372, 
and 96375. Payment may not be made by carriers for these services when they are provided to hospital 
inpatients or patients in a hospital outpatient department for these CPT codes. These codes were billed with a 
place of service of 23 (emergency room-hospital). This means payment for these codes cannot be made as 
billed. Code A4649 has a status indicator of P. No separate payment is made for this code under the fee 
schedule. 
 
Based on this information, we decided that Medicare rules for coverage of procedure code 96365, 96366, 
96372, 96375, and A4649 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 96365, 96366, 96372, 96375, and A4649 billed for date of service October 23, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve nasal sinus surgery. 
 
You asked the Plan to pre-approve nasal surgery. You say that the enrollee has a nasal obstruction. The Plan 
denied your request. The Plan says that there is no clinical indication for this technology. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 nasal surgery. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found sinuplasty has been shown to be an effective treatment option which can reduce symptoms and 
improve quality of life in selected patients with chronic sinusitis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasal surgery have been met. Therefore, we decided that the Plan has to pre-
approve nasal sinus surgery.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Kajinti. 
 
You asked the Plan to pre-approve Kajinti. 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 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 Kajinti. Our reviewer says that the 
services are medically necessary. Our physician reviewer found Taxol with Kajinti is an approved adjuvant 
therapy for stage IA human epidermal growth factor receptor 2 (her 2)/neu+ breast cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kajinti have been met. Therefore, we decided that the Plan has to pre-approve 
Kajinti.  
 
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: 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the enrollee does not require skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to provide medically necessary and 
reasonable treatment safely and effectively. Records do not document the need for intravenous medications, 
new ostomy care, daily complex wound care or respiratory care. He is reported to be tolerating the tube feeds at 
goal rate with no complications. Uncomplicated tube feeding alone does not meet Medicare criteria for daily 
inpatient skilled nursing care. The enrollee does not require skilled therapy services. There is no documentation 
that daily skilled services are required. The enrollee is walking household to community distances with a 
wheeled walker with no hands-on help and is transferring with no hands-on help. Provided records do not 
document a significant decline in the enrollee's functional status compared to his recent baseline to necessitate 
daily inpatient skilled therapy services. The enrollee does not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Records support those services in the home with home health care or in a long-
term care facility on a part time basis are appropriate in this case. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device (0266T, C1825). 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the Barostim NEO device has not been shown to improve survival. It 
has not been shown to prevent or reduce hospitalization. It has not been shown to improve heart muscle 
pumping function (ejection fraction) per FDA labeling. Placement of the Barostim Neo system is not medically 
necessary for this enrollee and is 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 a Barostim Neo device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found baroreflex stimulation devices have been considered potential alternative treatments 
for resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator 
implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse 
generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the 
carotid arteries. In August 2019, the FDA approved the system for use in enrollees 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%, and are not candidates for bi-ventricular pacing. This was based on a clinical 
study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved 
cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of Barostim Neo in enrollee 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 a Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device (0266T, C1825).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
(K0856), a power tilt system (E1002), and accessories (E0955, E1012, E1028, E2311, E2313, E2359, E2377, 
E2607, E2620). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with a single power option, a power tilt system, 
and accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the 
requirements for coverage have not been met.  
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with a single power 
option is covered if the beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick or the beneficiary meets coverage criteria for a power tilt or a power recline 
seating system and the system is being used on the wheelchair.  If the power wheelchair base is not covered, 
then related accessories will be denied. 
 
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 group 3 power wheelchair with a 
single power option, a power tilt system, and accessories. Our reviewer says that the requested power 
wheelchair is not medically necessary. Our physician reviewer found there is inadequate clinical 
documentation regarding why the enrollee requires a power tilt and cannot perform pressure relief. The 
enrollee is independent with his daily activities and requires minimal assistance for transfers. He does not have 
impaired sensation and does not have a history of skin breakdown. 
 
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 group 3 power wheelchair with a single power option, a power tilt system, and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with a single power option (K0856), a power tilt system (E1002), and accessories (E0955, 
E1012, E1028, E2311, E2313, E2359, E2377, E2607, E2620).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation. 
 
You asked the Plan to pre-approve the non-emergent transportation. You say that you are on dialysis 
treatments, have a broken ankle and an open wound on the bottom of your foot. The Plan denied your request. 
The Plan says you have no medical need for non-emergency ambulance medical transportation and can use 
other means of transportation. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergent transportation. Our 
reviewer says that the non-emergency transportation service is not medically necessary. Our physician reviewer 
found transportation via ambulance to/from hemodialysis is not medically necessary. You are not bedbound as 
evidenced by your ability to leave the house for medical appointments and to sit in a wheelchair. There is no 
evidence that you require the expertise of trained personnel or the equipment available only on an ambulance in 
order to effectuate a safe transport. 
 
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 non-emergent transportation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve non-emergent transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hypoglossal Nerve Stimulator. 
 
You asked the Plan to pre-approve the Hypoglossal Nerve Stimulator. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that Hypoglossal Nerve Stimulation is covered when 
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 the Hypoglossal Nerve Stimulator. Our 
reviewer says that the requested device is not medically necessary. Our physician reviewer found there is 
insufficient documentation supporting CPAP failure in this enrollee, or CPAP intolerance. 
 
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 Hypoglossal Nerve Stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Hypoglossal Nerve Stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a positron emission tomography (PET) scan of the brain. 
 
You asked the Plan pre-approve a PET scan. You say that you are requesting reconsideration for the denial of a 
PET scan. The Plan denied your request. The Plan says the request does not meet Medicare or the Plan's 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules state that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months 
who meet certain diagnostic criteria. 
 
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 pre-approve a PET scan. Our reviewer says that a PET 
scan is not reasonable and necessary and does not meet Medicare criteria for coverage. Our physician reviewer 
found the notes provided for review did not readily suggest that the enrollee was suspected of having either 
Alzheimer's Disease or frontotemporal dementia. There were possibilities raised of Lewy body dementia or 
multiple system atrophy like syndromes. However, there was nothing present in the records to suggest a 
differential diagnosis of Alzheimer's Disease. 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have pre-approve a positron emission tomography (PET) scan of the brain.
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 services for a SNF admission are medically 
necessary. The Plan denied your request. The Plan says the requested SNF services are 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 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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Services required can be provided in an alternate level of care, such as home health care or a long-term 
care facility on a part-time basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 18, 2022, to July 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient hospital care. You say that there were no in-network beds available. 
You also say that this should be reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The record shows that the enrollee was stable 
for transfer. The Plan did not pre-approve the service at issue. We found no exception that would require the 
Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for inpatient 
hospital care provided from July 18, 2022, to July 22, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37220, 34713-59-LT, and 34713-RT 
provided on April 25, 2022. 
 
You asked the Plan to pay for procedure codes 37220, 34713-59-LT, and 34713-RT. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 
not covered as billed. 
 
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, we have confirmed that code 37220 is a column II code to column I code 34705; however, 37220 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 37220. Our reviewer says that the medical 
records do not support the use of modifier 59 billed with code 37220. Our reviewer found the operative report 
describes intravascular angioplasty right common iliac artery and endovascular aneurysm repair left and right 
iliac limb. In this case, modifier -59 cannot be verified as a distinct procedural service, and therefore CPT 
37220 would not be reported separately from CPT 34705. 
 
Medicare rules also say that claims submitted where the unit of service exceeds the MUE value cannot be paid 
when the MAI value is 2. In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. 
You billed 2 units of this code, exceeding the MUE. Specifically, you billed one line item of this code with the 
LT modifier and one line item of this code with the RT modifier instead of billing one line item with the 
bilateral modifier as is required. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37220, 34713-59-LT, and 34713-RT have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 37220, 34713-59-LT, and 34713-
RT provided on April 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal ctDNA test provided on  
August 2, 2021. 
 You asked the Plan to pay for the Guardant Reveal ctDNA test. You say that the Guardant Reveal ctDNA test 
was medically necessary. The Plan denied your request. The Plan says the Guardant Reveal ctDNA test is not 
medically necessary. 
 
The Plan follows Medicare rules.  
 
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 Guardant Reveal ctDNA test. Our 
reviewer says that the Guardant Reveal ctDNA test is not medically necessary. Our physician reviewer found 
that the enrollee is a 66-year-old with stage IIIA cecal colon adenocarcinoma treated with 
hemicolectomy in March 2021 and completed FOLFOX therapy in June 2021. The only clinical documentation 
is an oncology note dated June 8, 2022, that was submitted with a prior case. No additional clinical records 
were submitted with this particular request. Per NCCN guidelines on colon cancer version 2.2022: In summary, 
the information from these tests can further inform the risk of recurrence over other risk factors, but the panel 
questions the value added. Furthermore, evidence of predictive value in terms of the potential benefit of 
chemotherapy is lacking. The review has determined that the requested Guardant Reveal ctDNA test does not 
meet the Medicare LCD coverage criteria. 
 
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 Guardant Reveal ctDNA test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant Reveal ctDNA test provided on August 2, 2021.