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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 21, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 21, 2023, forward. You say that 
the services are medically necessary. The Plan denied your request. The Plan says the services are 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 psychiatric care from 
September 21, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 21, 2023, forward. Our 
physician reviewer found the progress notes do not indicate that the enrollee had been aggressive with peers or 
staff on the unit or had had any recent attempt to harm herself as of the last covered date. There was no 
indication in the available medical records that the enrollees psychiatric symptoms could not be managed on a 
less restrictive basis as of the last covered date. The enrollee was noted to have confusion at her baseline 
mental status. The enrollee was not exhibiting any other significant symptoms such as mania. She had no acute 
psychiatric issues that would require continued inpatient care. The enrollee has chronic symptoms. The 
available medical records do not support that inpatient care would have changed these symptoms or the 
enrollees current condition. The enrollee is chronically impaired due to major neurocognitive disorder and the 
continued inpatient hospital stay was not expected to improve the enrollees condition in a reasonable period of 
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 inpatient psychiatric care from September 21, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 21, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on May 4, 2023. 
 
You asked the Plan to pay for the anesthesia. You say that you have submitted supporting documentation and 
are appealing the denial of these services. The Plan denied your request. The Plan says this service is excluded 
from coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local anesthesia 
in conjunction with operative or surgical procedures (D9215) provided on May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system for 9 additional months. 
 
You asked the Plan to pre-approve the home ventilator system. You say that the enrollee has multiple 
admissions for COPD, Obesity hypoventilation syndrome (OHS) and chronic respiratory failure. You say that 
the enrollee needs the ventilator to help normalize carbon dioxide and decrease hospital admissions. The Plan 
denied your request. The Plan says a home ventilator is not medically necessary for this patient because their 
needs can be met with an alternative device such as a BiPAP device with average volume-assured pressure 
support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that continued use on a home ventilator is not medically necessary. Our physician reviewer found that the 
enrollee has a diagnosis for chronic respiratory failure due to obesity hypoventilation syndrome with reported 
thoracic restrictive disease. However, there is no detailed information to meet Medicare criteria for coverage of 
a ventilator as opposed to a BiPAP device with AVAPS and a backup rate. Therefore, the coverage criteria for 
an additional nine months of the home ventilator system is not met. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system for 9 additional months.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological testing. 
 
You asked the Plan to pre-approve psychological and neuropsychological testing. You say that the testing is 
needed to determine the stability of your patients in hopes of being able to safely treat them with a spinal cord 
stimulator. The Plan denied your request. The Plan says that the Plan does not see that a mental illness or 
psychological abnormality is suspected and it is unlikely that such testing would be necessary to support 
diagnosis or management of a mental health condition.  
 
The Plan follows Medicare rules. Medicare rules say that psychological and neuropsychological testing is 
covered when the criteria listed in the Medicare rules section of this decision 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 psychological and neuropsychological 
testing. Our reviewer says that the requested psychological and neuropsychological testing is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee with diagnoses 
including chronic pain, diabetes mellitus, chronic lung disease and hypertension. The most recent 
documentation indicates the enrollee is being evaluated for a possible implantation of a spinal cord stimulator 
for the treatment of chronic pain. There is no indication that the enrollee has had any problems or decrease in 
cognition or function. There is no documentation that supports the enrollee has mental illness or any psychiatric 
diagnoses. There are no abnormal screening tests such as a Mini-Mental State Examination (MMSE) or 
Montreal Cognitive Assessment (MoCA). There is no clear documentation available for review that would 
indicate a medical reason for formal neuropsychiatric or psychological testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve psychological and neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-
cement or re-bond of a crown (D2920) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraoral imaging (D0210). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 23, 2023. 
Therefore, we decided that the Plan does not have to pre-approve intraoral imaging (D0210).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx testing (0037U) billed for date of service March 
16, 2023. 
 
You asked the Plan to pay for FoundationOne CDx testing. You say that this test was medically necessary and 
was reported appropriately. The Plan denied your request. The Plan says that this claim was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of FoundationOne CDx testing have been met. Specifically, the specimen in this case was a tissue 
sample which would have been collected during a medically necessary and appropriate hospital stay, and the 
test itself was performed after discharge. It is also likely the sample was stored for some time. Based on the 
documentation provided, one of the exceptions has been met, which means that the appropriate date to report in 
this case would be the date the test was performed. In this case, the correct date is March 16, 2023. Therefore, 
we decided that the Plan has to pay for FoundationOne CDx testing (0037U) billed for date of service March 
16, 2023.  
 
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 RFA. 
 
You asked the Plan to pre-approve the RFA. You say that you are in a lot of pain and depend on these 
injections for relief. The Plan denied your request. The Plan says the request 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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that RFA is considered experimental/investigational and is not medically necessary for the 
treatment of chronic low back pain. 
 
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 RFA.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records substantiate the services 
billed. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on January 5, 2023. A comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date. Based on this information, 
we decided that the Medicare rules for the billed services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing billed for date of service December 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injections (64483 and 64484). 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not 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 the injections. Our physician reviewer found the most recent epidural steroid injection was on July 12, 2023, and there is no documentation of at least 50 percent of sustained improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at least three (3) months. In addition, the requested epidural will not be using a different approach, level and/or medication. The review has determined that the requested epidural steroid injection is not medically necessary or 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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the epidural steroid injections (64483 and 64484).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 81456 billed for date of service January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an infusion pump (E0781-RR) provided from October 5, 
2022, to October 19, 2022. 
 
You asked the Plan to pay for an infusion pump. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased. Modifiers KH, KI, and KJ indicate the capped rental month periods. 
 
We looked at the file and Medicare rules. The item at issue was not billed with modifier KH, KI, or KJ. Based 
on this information, we decided that Medicare rules for coverage of an infusion pump have not been met. 
Therefore, we decided that the Plan does not have to pay for an infusion pump (E0781-RR) provided from 
October 5, 2022, to October 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve myocardial imaging. 
 
You asked the Plan to pre-approve the stress test. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 the stress test. Our reviewer says that 
the request is medically necessary. Our physician reviewer found that the enrollee has a history of left bundle 
branch block. As such, the ECG shows an uninterpretable pattern. There is sufficient documentation to support 
the medical necessity for the requested cardiac stress testing in the enrollee's 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 the stress test have been met. Therefore, we decided that the Plan has to pre-
approve myocardial imaging.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on April 6, 2023. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered by 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. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal testing (81479) provided on April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for January 13, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately paid. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Procedure code 99204 has an OPPS status indicator of B, which 
means the code is not recognized and payable by the OPPS. Therefore, we decided that the Plan does not have 
to pay for procedure code 99204 billed for January 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for spine surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental when used as bone graft material in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for spine surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87491 billed for date of service May 27, 
2022. 
 
You asked the Plan to pay for procedure code 87491. You say that these services were coded appropriately. 
The Plan denied your request. The Plan says This code is not supported in the records provided. 
 
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 87491 is chlamydia trachomatis, amplified probe 
technique. 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 code 87491. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the laboratory report does not include documentation 
of Chlamydia trachomatis, and therefore cannot be verified.  
 
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 code 87491 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87491 billed for date of service May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9604 billed for date of service February 24, 
2023. 
 
You asked the Plan to pay for procedure code P9604. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported as 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 P9604 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 We find that CPT code P9604 is not supported in the medical record. Specifically, the records provided do not 
detail any travel in connection with the specimen collected in this case. Based on this information, we decided 
that Medicare rules for coverage of procedure code P9604 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code P9604 billed for date of service February 24, 2023.