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

 
We decided that the Plan does not have to pre-approve left atrial appendage closure (LAAC) and 
transesophageal electrocardiogram (TEE). 
 
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 LAAC and TEE 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 enrollee has elevated risk of 
thromboembolic stroke due to atrial fibrillation and an elevated congestive heart failure, hypertension, age, 
diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex 
category (CHADS2VASC) score. There is no documentation of an evidence-based shared decision-making 
interaction on anticoagulation. The LAAC with TEE is 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 left atrial appendage closure (LAAC) and transesophageal electrocardiogram (TEE).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guidance UTI test provided on February 23, 2023. 
 
You asked the Plan to pay for the Guidance UTI test. You say that this testing should be covered. The Plan 
denied your request. The Plan says this testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this 
information, we decided that Medicare rules for coverage of the Guidance UTI test have not been met. Therefore, we decided that the Plan does not have to pay for the Guidance UTI test provided on February 23, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 23, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve electrolysis. 
 
You asked the Plan to pre-approve electrolysis. You say that you need electrolysis for your ongoing medical 
condition of folliculitis. The Plan denied your request. The Plan says that the electrolysis is currently covered 
by the Plan for transgender care services only. Electrolysis is not covered for folliculitis, as it is not medically 
indicated. 
 
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 electrolysis. Our reviewer says that the 
requested electrolysis is considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have dissecting cellulitis/follicular decalvans that failed all other treatments. Electrolysis is 
standard 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 electrolysis have been met. Therefore, we decided that the Plan has to pre-
approve electrolysis.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for admission. 
 
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 enrollee's 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 14, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
all the records show that it was necessary for the enrollee to be transported by ambulance. You also say that the 
enrollee was at high risk for falls and other injury if they were not medically supervised. The Plan denied your 
request. The Plan says this service was not medically necessary. 
 
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 pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the hospital to the 
enrollees care facility was not medically necessary. Our physician reviewer found the enrollee did not require 
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees condition. Our reviewer also found that a prudent layperson would not 
believe that immediate medical attention was required for someone who was being discharged from the 
hospital. 
 
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-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided there is no documentation that 
the ultrasound guided radiation therapy at issue in this case meets all Medicare criteria for medically reasonable 
and necessary for the enrollee. Guidelines of the National Comprehensive Cancer Network do not support medical necessity of ultrasound guided radiation therapy for treatment of basal cell carcinoma of the skin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram provided on September 16, 2022. 
 
You asked the Plan to pay for an echocardiogram. You say that due to being non-ambulatory, choosing an in-
network provider was not an option. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an echocardiogram 
provided on September 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Addition for left leg. 
 
You asked the Plan to pre-approve a prosthesis. You say that this prosthetic is medically necessary. The Plan 
denied your request. The Plan says advanced feet and the left alignable system are not reasonable and 
necessary for the approved prosthesis. 
 
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 prosthesis. Our reviewer says that the 
medical criteria for a lower limb prosthesis have not been met. Our physician reviewer found documentation 
does not support that the enrollee requires a replacement L5910. There is no evidence in the treatment 
physician notes that the enrollee's L5910 is damaged beyond repair.  
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Addition for left leg.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
February 13, 2023. 
 
You asked the Plan to pay for procedure codes 96365 and 96366. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
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, the CPT Code Manual definition of code 96365 is: Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is: Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). 
 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 96365 and 96366. Our reviewer says that 
procedure codes 96365 and 96366 do not meet criteria for payment. Our reviewer found that the medical 
records provided indicate the patient had Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or 
continuous, by any means, on February 13, 2023, which is represented by a different code (G9197). In addition, 
OIVIT is a nationally non-covered service by Medicare and therefore is not eligible for reimbursement. 
Procedure code 96366 is an add-on code and is only eligible for reimbursement if the primary code is eligible 
for reimbursement. Since the primary procedure 96365 is not eligible for reimbursement in this case, neither is 
code 96366. 
 
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 96365 and 96366 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service February 13, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a drive medical nitro duet rollator and transport 
wheelchair combo (E1399). 
 
You asked the Plan to pre-approve a rollator and transport wheelchair combo. You say that you cannot walk 
without the rollator and even with the rollator, you can do very minimal walking because of your pain. The 
Plan denied your request. The Plan says the requested item is a convenience item. 
 
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 
considered a convenience item. Therefore, we decided that the Plan does not have to pre-approve a drive 
medical nitro duet rollator and transport wheelchair combo (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the human papilloma virus (HPV) testing by nucleic acid 
provided on November 14, 2022.   
You asked the Plan to pay for the genetic HPV testing. You say that this should be approved due to medical 
necessity. The Plan denied your request. The Plan says this was billed with a screening diagnosis code, but the 
diagnostic procedure code was reported. This is not covered as screening with the billed procedure code. 
 
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. 
 
While the test at issue may be appropriate, this was billed with a diagnostic procedure code, but the claim did 
not report signs/symptoms. This was solely reported for screening purposes for which there are specific codes.  
Therefore, we decided that the Plan does not have to pay for the human papilloma virus (HPV) testing by 
nucleic acid provided on November 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued behavioral health inpatient stay from July 
22, 2023, forward.  
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found you do not meet the criteria for treatment in an acute inpatient/detoxification 
beginning July 23, 2023, forward and could have been treated in a lesser restrictive setting as you were not 
showing any withdrawal symptoms, medical issues and was not showing any suicidal or homicidal ideation, 
auditory or visual hallucinations, delusions. You were not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety. You were not showing any 
withdrawals from alcohol. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued behavioral health inpatient stay from July 22, 2023, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 23, 2023, billed with 
procedure code 92134. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed inappropriately with 
diagnosis codes H43.821 and H43.822. As this is a unilateral/bilateral procedure, and there is a bilateral 
diagnosis provided, the claim should be billed with a higher level of specificity. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on February 23, 2023, billed with procedure code 
92134.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on July 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that procedures 
designated as bilateral should not be billed with multiple units. 
 
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. The Plan argues that procedures designated as bilateral should not be billed with 
multiple units. However, the Plan has not provided a Medicare rule supporting its denial. The Plan has not 
provided detailed documentation showing why the billed codes are not payable as billed in this case. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services provided on July 26, 2022.  
 
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 enrollee clearly meets Medicare Criteria for 
Skilled Nursing Facility Placement and has sufficient medical and physical complexity supporting this 
discharge plan. The Plan denied your request. The Plan says the enrollee's records do not show that daily 
skilled services can be provided only on an inpatient basis in a SNF. Services needed may be provided safely in 
a lower level of care. 
 
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 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.