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

We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on January 4, 2022.
You asked the Plan to pay for the Guardant360 CDx testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the exceptions to the general rule for date of service would not apply in this case.
The Plan must follow Medicare rules. Medicare rules say that the general rule for the date of service (DOS) policy for either a clinical laboratory test or the technical component of physician pathology service is to bill the date the specimen was collected as the date of service. Maximus overturned the Plan's denial. The Plan requested a reopening stating that the specimen was obtained in a laboratory and has the incorrect date of service on the claim form. The claim shows a Place of Service of an independent laboratory. The rules state that the date of service submitted on the claim form must be the date the specimen was collected if the specimen was collected in a laboratory. The specimen was collected on December 28, 2021, but the date of service on the claim form was April 6, 2022. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing provided on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The enrollee is not currently using insulin. Based on this information, 
we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the FreeStyle Libre 2 sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01830) provided on May 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 01830 is "Anesthesia for open or surgical 
arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified". 
 
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 the services. Our reviewer says that the use of code 01830 is 
not supported by the records provided. Our reviewer found that the record does not clearly state what time the 
anesthesia services began. There are two anesthesia start times documented. The record is not clear regarding 
which start time should be used to calculate anesthesia time. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services (01830) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an application of skin substitute graft to trunk, arms, 
legs, total wound surface area (15271). 
 
You asked the Plan to pre-approve an application of skin substitute graft. You say that you disagree with the 
denial and are requesting reconsideration. The Plan denied your request. The Plan says there is not enough 
scientific proof showing the safety and/or success for Alloderm when used for this reason. It falls under the 
class of experimental and unproven and is not covered by the Plan. 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 an application of skin substitute graft. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found AlloDerm, an intact acellular dermal matrix, is intended to be used for 
repair of replacement of damaged or inadequate integumental tissue or for other homologous uses of human 
integument. The enrollee does not meet criteria for the requested skin substitute because the LCD states that 
Medicare covers application of skin substitutes to ulcers or wounds that have had failed responses. 
Reimbursement may be made only when the medical record clearly documents that these products have been 
used in a comprehensive, organized wound management 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 an application of skin substitute graft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an application of skin substitute graft to trunk, arms, legs, total 
wound surface area (15271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve a crown. You say that D2740 is medically necessary. The Plan denied your 
request. The Plan says the medical criteria for D2740 have not been met. 
 
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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that  Our 
physician reviewer found the medical criteria for D2740 have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) (64493, 64494). 
 
You asked the Plan to pre-approve MBBs. You say that the injections are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who have no evidence of 
radiculopathy or neurogenic claudication. 
 
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 MBBs. Our reviewer says that the 
requested MBBs are not medically necessary. Our physician reviewer found the provided documentation shows 
evidence of radiculopathy. the reviewer found that the enrollee has received multiple epidural steroid injections. The reviewer found there is non-facet pathology per clinical assessment or radiology studies that 
could explain the source of the enrollee's pain, including but not limited to fracture, tumor, infection, or 
significant deformity. Therefore, the reviewer found that the requested MBBs are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medial branch blocks (MBBs) (64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cold or hot fluid bottle, ice cap or collar, heat and/or 
cold wrap, any type (A9273). 
 
You asked the Plan to pre-approve a heat wrap. You say that the heat and cold pack help to relieve your neck 
pain. The Plan denied your request. The Plan says the requested heat wrap is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve cold or hot fluid bottle, ice cap or collar, heat and/or cold 
wrap, any type (A9273).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve an HFCWOD. You say that you would like the Plan to allow this therapy as 
prescribed by the enrollee's physician. The Plan denied your request. The Plan says this is not a covered service 
under the Plan for an enrollee who lives in a nursing home. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 
 
 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 an HFCWOD. Our reviewer says that a 
high-frequency chest wall oscillation device (HFCWOD) is not medically necessary. Our physician reviewer 
found the enrollee has severe obesity, pulmonary hypertension, chronic inflammatory demyelinating 
polyneuropathy with leg weakness, and Heart failure with preserved ejection fraction (HFpEF). The physician's 
note indicates a diagnosis of bronchiectasis, based on dilated airways seen on a chest computed tomography 
(CT) scan from March 2022. However, our reviewer found that the report of that scan, dated March 25, 2022, 
specifically indicates no dilated airways and no bronchiectasis. There is no diagnosis of cystic fibrosis. There is 
a diagnosis of chronic inflammatory demyelinating polyneuropathy, but the records do not indicate that this is 
impairing pulmonary function. Our physician reviewer also found that a recent amount of air exhaled measured 
during the first second of the forced expiratory volume breath (FEV1) was within normal limits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high-frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87088) provided on August 29, 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 records do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87088 is Urine Culture, Bacterial. 
 
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 the lab services. Our reviewer says that the code billed is not 
supported by the records. Our reviewer found there was no culture listed as being performed or the results of 
the culture in the provided records. 
 
We looked at this coder's review, the file, and Medicare rules. 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 (87088) provided on August 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
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 enrollee does not require inpatient rehabilitation services. The IRF is not a 
medical step-down unit or an area to continue hospital services. 
 
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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer Procedure. 
 
You asked the Plan to pre-approve the VivAer Procedure. You say that the records provided support the need 
for the requested procedure. The Plan denied your request. The Plan says there is not enough medical proof that 
shows the safety and success of VivAer procedures when used for the repair of nasal valve collapse. 
 
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 VivAer Procedure. Our reviewer 
says that the VivAer Procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal congestion and epistaxis with nasal 
valve collapse. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. 
 
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 VivAer Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer Procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 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 a sleep study is covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of obstructive 
sleep apnea (OSA) based on a home sleep study in 2015. He has been on home continuous positive airway 
pressure (CPAP) since then, but the device now requires replacement. There is no indication in the notes that 
he is having problems with the CPAP or its effectiveness. There is no question of the diagnosis of OSA. The 
requested sleep study is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual tilt and recline accessories for a wheelchair. 
 
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 manual tilt and recline are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that the 
enrollee is at high risk for skin breakdown, has spasticity, or uses intermittent catheterization. The criteria for 
coverage of the manual tilt and recline are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve manual tilt and recline accessories for a wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from August 5, 2022, 
through March 1, 2023. The Plan has covered 100 days of SNF care. Although the enrollee may still need 
skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. 
The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a 
hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have 
to pre-approve continuation of SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95718 billed for date of service January 9, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code remains 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95718 is electroencephalogram (EEG), continuous 
recording, physician or other qualified health care professional review of recorded events, analysis of spike and 
seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG) 
 
We find that CPT code 95718 is not supported in the medical record. Specifically, the records do not support 
that the billed services were provided on the date of service at issue. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 95718 billed for date of service January 9, 2022.