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 long term acute care admission is needed 
for complex medical necessity. The Plan denied your request. The Plan says long term acute care admission is 
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 enrollee appears to be improving with the current treatment and does not require 
services at the LTACH that are not already available at the current facility.   
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that this is medically necessary. The 
Plan denied your request. The Plan says based on the additional information available, the request does not 
meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that at issue is the appropriateness and medical necessity of implanting 
an ILR in the clinical management of this patient. The patient had no history of atrial fibrillation, nor were any 
significant cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that 
continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients 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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee has not walked in two years 
and these services are medically necessary. The Plan denied your request. The Plan says that the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
had been functionally non-ambulatory due to prior foot fracture, which required non-weight bearing. He has 
received 20 session of home health physical therapy and has made progress in terms of his ability to ambulate 
with a walker and/or cane. He continues to have difficulty ambulating due to unsteadiness and requires minimal 
to contact guard assistance with walking and going up and down stairs. He would benefit from additional 
therapy to improve his stability and decrease his risk for falling as well as negotiating stairs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
has to pre-approve home health physical therapy services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the destruction by neurolytic agent of the genicular 
nerve (64624). 
 
You asked the Plan to pre-approve the destruction by neurolytic agent of the genicular nerve. You say that you 
are in pain and will benefit from this procedure. The Plan denied your request. The Plan says your request is 
not medically necessary because based on the medical literature this procedure is considered experimental or 
investigational and has not been proven to be beneficial for your condition. 
 
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 destruction by neurolytic agent of 
the genicular nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that genicular nerve block is experimental for knee pain. Thus, this procedure is not considered 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 destruction by neurolytic agent of the genicular nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the destruction by neurolytic agent of the 
genicular nerve (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit provided on August 31, 2023. 
 
You asked the Plan to pay for the outpatient visit. You say that you are requesting reconsideration for the 
services provided. 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 the outpatient visit 
provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 8, 2022, billed with 
procedure codes 95999 and 95910-26. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 95999 and 95910 is unlisted neurological or 
neuromuscular diagnostic procedure, and nerve conduction studies; 7-8 studies. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that documentation does not support the billed codes Our reviewer found that the provider reported an unlisted 
procedure code to support T04 testing. It is not appropriate to bill separately for train-of-four (TOF) 
monitoring, as this procedure is inclusive to primary neuromonitoring service. The American Medical 
Association (AMA) has clearly stated that CPT code 95937 is not appropriate for this procedure, nor may TOF 
monitoring be billed with an unlisted code. The procedure report does not include documentation of nerve 
conduction studies, however, does describe pedicle screw stimulation, which would not be reported with nerve 
conduction studies. There is a more specific code to report for pedicle screw stimulation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 8, 2022, billed with procedure codes 
95999 and 95910-26.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
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 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 records show that the enrollee's care requires intravenous (IV) antibiotics 
and wound care which can be provided at a lower level of care.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 1, 2023, billed with 
code Q5118-JZ. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 Q5118 is injection, bevacizumab-bvzr, biosimilar, 
(zirabev), 10 mg. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the procedure report documents 
bevacizumab, however, does not include sufficient documentation to support dosage and route and procedure 
report. As such, this procedure 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 the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 1, 2023, billed with code Q5118-JZ.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15860 rendered on May 3, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this procedure is disallowed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
operative report describes a omental pedicle flap with indocyanine green (ICG). In this case, as the service was 
performed in the same anatomical area, it therefore would not be separately reported.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 15860 rendered on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant 360 genetic testing provided on May 23, 2023, 
billed with code 81479. 
 
You asked the Plan to pay for a Guardant 360 test. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says this molecular pathology testing was not reported with the correct 
procedure code. 
 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. The Plan included evidence that the proper procedure code for the 
testing with Z-code ZB1CW is 0326U. This is not the code that was billed on this claim. Based on this 
information, we decided that Medicare rules for coverage of a Guardant 360 test have not been met. Therefore, 
we decided that the Plan does not have to pay for Guardant 360 genetic testing provided on May 23, 2023, 
billed with code 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 30, 2023, billed 
with procedure code 96413. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that documentation does not support the billed code. Our reviewer found that the medical record describes 
Golimumab infusion for rheumatoid arthritis. The documentation does not support chemotherapy 
administration was performed. Intravenous administration for Golimumab should be reported with a more 
specific procedure code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 30, 2023, billed with procedure code 
96413.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy with biopsy and moderate sedation billed 
with codes 45380 and G0500 provided on March 7, 2023. 
 
You asked the Plan to pay for the colonoscopy with biopsy and sedation. You say that the services were billed 
correctly and should be paid. The Plan denied your request. The Plan says two of the billed diagnosis codes 
cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that K63.5 has an Excludes1 note in relation to D12.4. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the colonoscopy with biopsy and sedation. have not been met. Therefore, we decided that the Plan 
does not have to pay for the colonoscopy with biopsy and moderate sedation billed with codes 45380 and 
G0500 provided on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urinary Tract Infection Panel provided on April 24, 
2023. 
 
You asked the Plan to pay for the Urinary Tract Infection Panel. You say that the urinary tract infection panel 
provided was medically necessary. The Plan denied your request. The Plan says the urinary tract infection 
panel provided was 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 Urinary Tract Infection Panel. Our reviewer says that the urinary tract infection panel provided was not medically necessary. Our physician 
reviewer found a review of the medical literature in clinical practice guidelines, including by the Infectious 
Disease Society of America and Healthcare Infection Control Practices Advisory Committee (HICPAC), state 
that standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture 
and susceptibility studies.  In addition, there is lack of support for the clinical utility of large multiplex 
polymerase chain reaction (PCR) urinary tract infection panel tests. Urine PCR amplification techniques raise 
considerable concerns regarding contamination from one specimen to another, creating the potential for false-
positive results. The clinical interpretation of PCR results may also be challenging.  Amplification of organisms 
representing latent infection or colonization cannot be distinguished from active, clinically significant 
infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus 
further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative 
predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 
 
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 Urinary Tract Infection Panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the Urinary Tract Infection Panel provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and pay more for a 
limited oral evaluation (D0140) provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that in order to assess the problem, the provider 
needed to take a panoramic x-ray. You also say you cannot imagine a dentist, much less an oral surgeon, who 
would accept this as a reasonable rate for performing such an exam. The Plan denied your request. The Plan 
says your benefit for the panoramic radiographic image has already been exhausted. The Plan also says if you 
receive services from an out-of-network provider, you are responsible for any amount greater than the payment 
made by the Plan to the provider. 
 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 panoramic radiographic image was exhausted on date of service June 5, 2023. The 
record also shows you received a limited oral evaluation in the amount of $300. The Plan paid the allowed 
amount of $46. The service was received from an out-of-network provider, and you are responsible for any 
amount greater than the payment made by the Plan to the provider. This cost is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330) and pay more for a limited oral evaluation (D0140) provided on July 
12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on June 29, 2023. 
 
You asked the Plan to pay for the wound care services. You say that you are requesting reconsideration for the 
services provided. 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 the wound care services 
provided on June 29, 2023.