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

 
We decided that the Plan does not have to pay for the magnetic resonance angiography services coded as 
70544-26-59 provided on May 17, 2021. 
 
You asked the Plan to pay for the magnetic resonance angiography services. You say that this code should be 
separately approved for payment. The Plan denied your request. The Plan says this claim has denied correctly. 
 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 70544 is a column II code to column I code 70551 however, 70544 
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 the magnetic resonance angiography services. Our reviewer 
says that the documentation does not support payment for the code as billed. Our reviewer found the provider 
reported 70544 Magnetic resonance angiography, head; without contrast material(s) in addition to more 
comprehensive radiology procedure performed at same session. Documentation submitted was reviewed, and 
criteria for coverage have not been met. Per CMS "When a more extensive Magnetic Resonance Imaging is 
performed on the same site as a less extensive MRI, the less extensive MRI is bundled into the more extensive 
MRI.  The less extensive MRI procedure code(s) will be recovered as an overpayment(s)". In this case, CPT 
70544 would be inclusive to CPT code 70551. 
 
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 magnetic resonance angiography services have not been met. Therefore, we 
decided that the Plan does not have to pay for the magnetic resonance angiography services coded as 70544-26-
59 provided on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a liver biopsy during weight loss surgery. 
 
You asked the Plan to pre-approve a liver biopsy. The Plan denied your request. The Plan says the request for a 
liver biopsy during weight loss surgery is not medically 
 
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 liver biopsy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a routine liver biopsy is not indicated for all patients undergoing bariatric surgery. The 
biopsy alone does not change the natural history that weight loss and bariatric surgery will reverse or improve 
most cases of non-alcoholic steatohepatitis or fatty liver. The medical history does not support the need for 
liver biopsy for the enrollee 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 a liver biopsy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a liver biopsy during weight loss surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism and chair. 
 
You asked the Plan to pre-approve a seat lift mechanism and chair. You say that this is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that once standing the 
enrollee does not have the ability to walk as the enrollee is non-ambulatory. Based on this information, we 
decided that Medicare rules for coverage of a seat lift mechanism and chair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a seat lift mechanism and chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left ear cochlear implantation. 
 
You asked the Plan to pre-approve left ear cochlear implantation. You say that the requested left ear cochlear 
implantation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for left ear cochlear implantation. 
 
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 left ear cochlear implantation. Our 
reviewer says that the enrollee does not meet criteria for left ear cochlear implantation. Our physician reviewer 
found based on available clinical documentation, the requested services for left-sided cochlear implantation do 
not meet criteria for Medicare coverage. The health plans criteria for cochlear implantation require a diagnosis 
of bilateral moderate-to-profound Sensorineural hearing loss (SNHL) with limited benefit from appropriate 
hearing or vibrotactile aids. In this case, there was a diagnosis of unilateral (left-sided) severe to profound 
SNHL. The right ear demonstrated normal hearing. In summary, the requested services for left-sided cochlear 
implantation do not meet Medicare criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left ear cochlear implantation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve left ear cochlear implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor (CGM) provided 
on December 27, 2021. 
 
You asked the Plan to pay for the therapeutic CGM. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the criteria for coverage 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 documentation indicates that the enrollee does use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for the 
therapeutic continuous glucose monitor (CGM) provided on December 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device (E0936). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that this device is 
medically necessary for your condition. The Plan denied your request. The Plan says the Medicare criteria for 
coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous passive motion devices are devices 
covered for patients who have received a total knee replacement. 
 
We looked at the file and Medicare rules. In this case, the requested device is not being requested after a total 
knee replacement but after a shoulder injury. Based on this information, we decided that Medicare rules for 
coverage of a continuous passive motion exercise device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous passive motion exercise device (E0936).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on September 20, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says that the diagnosis code is inconsistent with 
the billed ambulance services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has denied payment based on the diagnosis code as billed. 
However, no rules or regulations were included with the Plans denial to substantiate the Plans denial of 
payment for ambulance services specifically based on the diagnosis code. In addition, there is no Local 
Coverage Determination or Local Coverage Article that specified diagnosis codes that should be billed with 
ambulance services. Therefore, we decided that the Plan has to pay for the ambulance services provided on 
September 20, 2021.  
 
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: 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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for congestive heart failure. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program.  While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk genetic testing panel provided on September 2, 
2021. 
 
You asked the Plan to pay for cardiac risk genetic testing panel. You say that this testing was medically 
reasonable and necessary. The Plan denied your request. The Plan says this is a noncovered screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The enrollee is not noted to have a personal history of heart disease. She has risk factors but no signs/symptoms 
of illness. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for cardiac risk genetic testing panel provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Blood smear, peripheral, interpretation (85060) provided 
on November 9, 2021. 
 
You asked the Plan to pay for code 85060. 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 a Professional Component (PC)/Technical 
Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the 
professional component of this procedure is only payable for inpatients. The services were billed with an 
outpatient place of service. Payment for this service cannot be made for hospital outpatients. Therefore, we decided that the Plan does not have to pay for the Blood smear, peripheral, interpretation (85060) provided on 
November 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. 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 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found based on the 
medical records provided there is no documentation that the enrollee requires the services on an inpatient basis, 
only in a skilled nursing facility setting. Further medical stabilization before acute hospital discharge appears 
indicated 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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic combinatorial pharmacogenic 
testing provided on October 4, 2021. 
 
You asked the Plan to pay for pharmacogenomic testing. You say that no basis exists for the Plan to deny 
coverage for this test. The Plan denied your request. The Plan says the denial of payment for this test is correct, 
because this test has not been shown to be useful and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the algorithms employed in combinatorial testing 
are not currently considered reasonable and necessary components of testing.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to 
pay for GeneSight Psychotropic combinatorial pharmacogenic testing provided on October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the clinical documentation provided supports the 
need for SNF care. The Plan denied your request. The Plan says the record does not show that the enrollee 
requires daily skilled nursing or skilled therapy in a SNF setting. The Plan says that the services required are 
custodial.  
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee appears 
unable and unwilling to participate in daily skilled therapy.  The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Venofer (J1756). 
 
You asked the Plan to pre-approve the Venofer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary. 
 
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 the Venofer. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition and the Medicare approved drug 
compendia does not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
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 Venofer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Venofer (J1756).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on April 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that all codes are payable. The Plan denied your 
request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 provided. In this case, the CPT Code Manual 
definition of code 23430 is tenodesis of long tendon of biceps. This documentation does not support a long 
tendon of bicep tenodesis was performed.  
 The CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 
or more discrete structures. The operative report does not include enough documentation to confirm extensive 
debridement in anterior and posterior compartments or chondroplasty/bone debridement or soft tissue in 
multiple areas where no other work was performed. 
 
The CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of 
subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when 
performed. The operative report does not describe decompression of decompression of subacromial space. The 
report describes a bursectomy.  
 
We looked at this coder's review, the file, and Medicare rules. The billed codes at issue are not supported in the 
medical records. 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 surgery services provided on 
April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you will not be able 
to tolerate 3 hours a day of intense therapies. 
 
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 physician reviewer found 
that you were admitted to the acute care hospital for a seizure. Your medical problems are stable. The 
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) supplies 
(K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you are not insulin treated with atleast three daily injections. 
 
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 documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) supplies (K0553).