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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the thyroid (60699). 
 
You asked the Plan to pre-approve the RFA. You say that you feel this is the most appropriate treatment option 
for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 pre-approve the RFA. Our reviewer says that the 
requested RFA for the thyroid is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that the April 2022 left thyroid nodule biopsy showed a 
diagnosis suspicious for follicular neoplasm. The documentation did not include any clarification of this 
diagnosis with a repeat biopsy pathology report. Therefore, the reviewer found that the requested is RFA is 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 the RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) of the thyroid (60699).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural injection.  
 
You asked the Plan to pre-approve the injection. You say that that although the enrollee reports to physical 
therapy their pain is gradually getting worse. The Plan denied your request. The Plan says a transforaminal 
epidural injection 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 pre-approve the injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that there is no imaging of the 
spine, and the previous epidural steroid injection did not provide 3 months of 50% pain relief as required by the 
LCD. Therefore, the request for a transforaminal epidural injection is not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transforaminal epidural injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  Doxil. 
 
You asked the Plan to pre-approve Doxil. You say that the services are medically necessary and need to be 
started given the aggressive pattern. The Plan denied your request. The Plan says the use of Doxil for 
osteosarcoma is not FDA approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Doxil. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found that there is no compendia support or 
literature support for regorafenib and Doxil.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Doxil have not been met. Therefore, we decided that the Plan does not have to 
pre-approve  Doxil.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a sleep study (95806). 
 
You asked the Plan to pre-approve a sleep study. You say that you suffer from sleep apnea, and you need a 
breathing scan or imaging done. The Plan denied your request. The Plan says that this request is not medically 
necessary. The Plan also says the information sent in does not show the results of a past sleep study that shows 
that you had sleep apnea and have been previously treated for this condition. 
 
The Plan follows Medicare rules. Medicare rules say that home sleep studies are only covered for the diagnosis 
of Obstructive Sleep Apnea. 
 
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 sleep study. Our reviewer says that a 
home sleep study is considered reasonable and medically necessary. Our physician reviewer found you have 
diabetes, chronic obstructive pulmonary disease, and hypertension. You were seen on April 6, 2023, with 
multiple complaints, including daytime somnolence and a feeling of the airway closing up when reclining. Our 
reviewer found that you are obese, and examination showed a Mallampati 4 airway. Snoring and witnessed 
apneas were documented. Our physician reviewer found that the snoring history, tired during the day, observed 
stop of breathing while sleeping, high blood pressure, body mass index (BMI) greater than 35 kilograms per 
metres squared (kg/m2) (or 30 kg/m2), age greater than 50 years, neck circumference greater than 40 
centimeters and male gender (STOP-Bang) score was 7. There is no prior history of a sleep study or a diagnosis 
of obstructive sleep apnea. Our reviewer also found that there is a high suspicion for obstructive sleep apnea 
and a home sleep study is reasonable.  
 
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 sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a sleep study (95806).  
 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 pay for the skilled nursing facility (SNF) services provided April 23, 
2021, to April 30, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation submitted does not support the PT/OT functional score. 
 
The Plan follows Medicare rules. Medicare rules say that SNF services must be billed correctly. 
 
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 SNF services. Our reviewer says that the 
documentation does not support the services billed. Our physician reviewer found there is no evidence of a 
weight, or low intake or anthropometric measurements or Medical Doctor notes supporting malnutrition. The 
GG collection sheet is undated and no other info is provided. Therefore, the services are not payable as billed. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided April 23, 2021, to April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service January 
20, 2023. 
 You asked the Plan to pay for procedure code(s) 88305. You say that this service was medically necessary and 
was reported correctly. 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) 88305. 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) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service January 20, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 the lab services provided on January 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76441 billed for date of service January 24, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76441 billed for date of 
service January 24, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95861 billed for date of service July 27, 
2021.  
 
You asked the Plan to pay for procedure code 95861. You say that this is not a bundled service and was two 
distinct units. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 95861 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 95861 billed for date of service July 27, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the CxBladder test billed for date of service October 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says that the test is not the standard of care. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the plan provided 
notice that the billed services would not be covered. Under Medicare rules, this means the billed services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the CxBladder test billed 
for date of service October 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left atrial appendage closure device (LAAC). 
 
You asked the Plan to pre-approve LAAC. You say that while the patient's current CHA2DS2-VASc score is 2, 
he will be a score 3 in October when he turns 75. You say that he has been having spontaneous hemorrhaging 
from being on blood thinners. The Plan denied your request. The Plan says based on Medicare guidelines; the 
percutaneous left atrial appendage closure does not meet the requirements for approval. 
The Plan follows Medicare rules. Medicare rules say that the patient must have A CHADS2 score  2 
(Congestive heart failure, Hypertension, Age > 75, Diabetes, Stroke/transient ischemia 
attack/thromboembolism) or CHA2DS2-VASc score  3 (Congestive heart failure, Hypertension, Age  65, 
Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular disease, Sex category). 
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 LAAC. Our reviewer says that the 
requested LAAC is not considered medically necessary in this case. Our physician reviewer found the 
Medicare guidelines would not support implantation of a LAAC in this enrollees setting. LAAC placement 
would not be considered reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an LAAC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left atrial appendage closure device (LAAC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says that this item is not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service 
November 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the services. The 
Plan denied your request. The Plan says the billed services 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 find that CPT code 99152 and 99153 is not supported in the medical record. Specifically, the records do not 
show that the services required the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 99152 and 99153 billed for date of service November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87636) provided on February 13, 2022. 
 
You asked the Plan to pay for the laboratory test. 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. 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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87636) 
provided on February 13, 2022.
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 your professional opinion that the enrollee will 
receive the appropriate level of care in the acute rehabilitation setting. You also say that further delay will have 
a detrimental effect on the enrollee's safety, ability to recover to the fullest extent, be discharged to a 
community setting, and stay in that community setting, averting unplanned readmissions. The Plan denied your 
request. The Plan says the IRF services requested do 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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that 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. Our physician reviewer also found that 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nonpneumatic compression controller with sequential 
calibrated gradient pressure (K1024) and nonpneumatic sequential compression garment, full leg (K1032). 
 
You asked the Plan to pre-approve a nonpneumatic compression controller and full leg nonpneumatic 
sequential compression garment. 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 a nonpneumatic compression controller 
and full leg nonpneumatic sequential compression garment. Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found a review of 
the current medical literature does not consider this Dayspring device to be standard medical treatment for the management of lymphedema. The review has determined that the items/services at issue in this case 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 a nonpneumatic compression controller and full leg nonpneumatic sequential 
compression garment have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
nonpneumatic compression controller with sequential calibrated gradient pressure (K1024) and nonpneumatic 
sequential compression garment, full leg (K1032).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VIA Disc procedure. 
 
You asked the Plan to pre-approve the VIA Disc procedure. You say that  you have suffered para mid-line back 
pain and are experiencing pain when you are walking. The Plan denied your request. The Plan says a VIA Disc 
procedure 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 pre-approve a VIA Disc procedure. Our reviewer 
says that a VIA Disc procedure is not medically necessary. Our physician reviewer found the requested VIA 
Disc procedure is considered an experimental and investigational procedure.  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 VIA Disc procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VIA Disc procedure.