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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for approval.  
 
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 is a 70-year-old who was admitted to the acute care hospital with 
intracranial hemorrhage requiring ventricular drain placement, mechanical ventilation support, and tube feeds. 
Recent notes describe the enrollee as now extubated on oxygen support via nasal cannula but with overall poor prognosis for recovery.  
 
1. The enrollee appears to not likely improve with long-term acute care and requires only short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer to a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. 
Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC (0315U) provided July 7, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDx-SCC test was 
denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says 
the request for DecisionDx-SCC is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for DecisionDx-SCC is not medically necessary. This test is also experimental and 
investigational at this point. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for DecisionDx-SCC (0315U) provided July 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45380). 
 
You asked the Plan to pre-approve a colonoscopy. You say that you and your doctor feel it would be in your 
best health interest to have a colonoscopy. The Plan denied your request. The Plan says your request for a 
diagnostic colonoscopy is not medically necessary because your records show you do not have symptoms, 
anemia, polyps, documentation of gastrointestinal bleeding, or an abnormality on barium enema or other 
imaging study. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare-covered indications for diagnostic 
colonoscopy are listed in the Medicare rules section of this letter.  
 
 
  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 colonoscopy. Our physician reviewer 
found the available records do not support that you are high risk for colon cancer by virtue of personal nor 
family history, have active lower gastrointestinal signs nor symptoms that warrant earlier than expected 
colonoscopy, nor have an imaging result that suggests colonic pathology. Our reviewer also found that 
indications provided for LCD coverage are not met to warrant performing the examination as requested. 
 
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45380).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service July 29, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. The Plan denied your 
request. The Plan says this code is included in the facility payment and is not separately payable.  
 
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 the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service July 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on January 24, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the supplies are not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that under SNF PPS all Medicare covered Part A 
services that are considered within the scope or capability of skilled nursing facilities (SNFs) are considered 
paid in the PPS rate.  
 
We looked at the file and Medicare rules. The supplies in this case were provided to the enrollee during a 
covered SNF stay. As such, the claim should be billed with POS 31, and payment is included in the PPS rate. 
The supplies are not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
supplies provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx (81479) provided on October 25, 2022. 
 You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that for molecular diagnostic tests, 
such as the test at issue, the MolDX program requires these tests to be reviewed to determine whether Medicare 
reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique 
identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim shows that the required unique identifier was 
reported, however, the records indicate that the CPT code used to report this test (81479) is not appropriate for 
the test at issue and is not listed as appropriate to combine with the unique identifier reported. Based on this 
information, we decided that Medicare rules for coverage of Guardant360 CDx have not been met. Therefore, 
we decided that the Plan does not have to pay for Guardant360 CDx (81479) provided on October 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 43212 provided on June 3, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and noted that this was not a denial involving the Status B indicator. The Plan notes that code 43212 was denied because its payment was included in the global package payment. Code 43775 has a global value of 090 on the National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This is a major procedure that has a global surgery period of 90 days. Payment for code 43212 billed on date of service June 3, 2022, is included within the global surgery package of code 43775 billed on date of service April 14, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 4312 could not be paid due to its relation to the global surgery payment for code 43775. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 43212 provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on July 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/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 nursing facility care provided on July 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says that the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of 
Orthovisc or Supartz Fx before they will approve Euflexxa. The submitted records do not contain 
documentation of trial and failure of Orthovisc or Supartz Fx. The documentation does not support that 
Orthovisc or Supartz Fx would likely be less effective or have adverse effects for the enrollee 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollees nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pleural effusion. Medical problems are stable. There are no complex nursing or rehabilitation 
needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF testing (81455) provided on January 3, 2023. 
 
You asked the Plan to pay for Tempus xF. You say that this test was medically necessary and reasonable. The 
Plan denied your request. The Plan says this test does not meet criteria for coverage. 
 
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 pay for Tempus xF. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found at the time this test was performed, the Tempus xF test was not FDA approved for use in this 
clinical scenario and for the enrollee's 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 Tempus xF have not been met. Therefore, we decided that the Plan does not 
have to pay for Tempus xF testing (81455) provided on January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on 
November 22, 2022, and December 22, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that you would like these TENS 
supplies to be reprocessed, as per the medical necessity criteria has been met. The Plan denied your request. 
The Plan says charges for or in connection with services or supplies that are, as determined by the Plan, 
considered to be experimental or investigational are excluded from coverage under the enrollee's plan. 
 
The Plan must follow Medicare rules. Medicare rules say that during the rental of a TENS unit, supplies for the 
unit are included in the rental allowance; there is no additional allowance for supplies. 
 We looked at the file and Medicare rules. The record shows that the enrollee received a neuromuscular 
stimulator rental on November 22, 2022, and December 22, 2022. Based on this information, we decided that 
Medicare rules for coverage of the electrical stimulator supplies have not been met. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator supplies (A4595) provided on November 22, 2022, 
and December 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to be up and move around without 
assistance. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to 
an IRF.  
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you may have a need for physical therapy and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you 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 an IRF admission and services.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the services requested are 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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge services (99239) provided on April 9, 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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not 
show that more than 30 minutes of hospital discharge day management services were provided on the date of 
service in question. 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 discharge services (99239) 
provided on April 9, 2022.
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 you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the services requested 
are not medically necessary. 
 
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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving. The enrollee still requires acute care services before transitioning to 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 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.