Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the enteral formula, manufactured blenderized 
natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include 
fiber, administered through an enteral feeding tube (B4149) purchase January 23, 2023, to February 23, 2023. 
 
You asked the Plan to reimburse you for the enteral formula. You say that while in the hospital the enrollee had 
to go on a feeding tube. The food the hospital provided was not appropriate as it had a milk component which 
the enrollee has reactions to. The Plan denied your request. The Plan says this item was purchased from a 
supplier who is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the enteral formula, 
manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins 
and minerals, may include fiber, administered through an enteral feeding tube (B4149) purchase January 23, 
2023, to February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 
87653, and 87798 for June 30, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87640, 87653, and 87798 for 
June 30, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter mitral-valve repair procedure (33418). 
 
You asked the Plan to pre-approve a transcatheter mitral-valve repair. You say that a transcatheter mitral-valve 
repair is a medical necessity for the enrollee. The Plan denied your request. The Plan says a transcatheter 
mitral-valve repair 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 transcatheter mitral-valve repair. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the consulting cardiologist indicates that appropriate treatment options for the 
enrollee include surgical mitral valve replacement (SMVR) as well as medical management. As such, the 
documentation is inadequate to confirm fulfillment of guidelines for a transcatheter mitral-valve repair.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transcatheter mitral-valve repair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a transcatheter mitral-valve repair procedure (33418).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on July 21, 2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the unbundling of lab codes for PCR panel testing is not appropriate.  
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on July 21, 
2023, and billed with codes 87481, 87500, 87640, 87652, 87798, 87799, and 87900.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqembi (J0174). 
 
You asked the Plan to pre-approve the drug. You say that the enrollee needs to start this drug. The Plan denied 
your request. The Plan says Leqembi is not reasonable and necessary for this 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 drug. Our physician reviewer found 
the record provided indicates that the enrollee has headache and neck pain and is insufficient to establish that 
the enrollee has mild cognitive impairment or mild dementia in the setting of early Alzheimer's disease. The 
Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The 
record provided does not document that the enrollee is enrolled in the required approved studies or 
registry. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Leqembi (J0174).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 17, 2022, to 
September 15, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 17, 2022. The NOA was not received by the Plan until May 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 17, 2022, to September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary in 
order to treat the enrollee's knee pain and improve quality of life, as the enrollee has ongoing pain, functional 
limitations, and a limited response to previous treatments for osteoarthritis. The Plan denied your request. The 
Plan says that this service is considered experimental/investigational to treat knee arthritis. 
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that there is insufficient literature to support the safety and efficacy, as 
defined by Medicare rules, of the requested service. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for payment for the inpatient rehabilitation facility (IRF) 
services provided from April 20, 2023, to May 19, 2023. 
 
You asked the Plan to pay for the services. You say that the facility does not accept your insurance which is 
why you are personally filing. The Plan denied your request. The Plan says the facility stay 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 pay for the services. Our physician reviewer found 
that it was not expected you would improve in a reasonable period of time beyond the dates in question as you 
were not showing any dangerousness to self or others and not showing any symptoms of severe withdrawal. 
You were cooperative and compliant with medication or any medical issues. It did not appear medically 
necessary and reasonable to have inpatient/detoxification provided at the acute inpatient level of care rather 
than a lower level of care beyond the dates in question as you did not have any withdrawal symptoms, medical 
issues, suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The Health 
Plans denial of continued inpatient/detoxification appears appropriate. You did not require 
inpatient/detoxification beyond the dates in question as noted above as you were not showing any withdrawal 
symptoms or any medical issues and were not a danger to yourself or others, you did not have any delusions or 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve your condition or for the purpose of diagnosis. Our physician reviewer was unable to find 
an individualized treatment plan; however, the entire record is not present. It appears that the services were 
supervised and evaluated by a physician. Based upon review the records provided, you do not meet the criteria 
for treatment in an acute inpatient/detoxification and could have been treated in a lesser restrictive setting as 
you were not showing any withdrawal symptoms, medical issues and were not showing any suicidal or 
homicidal ideation. You were not showing any behaviors or aggression being cooperative and compliant while 
not showing any acute threats to safety. She was not showing any withdrawals from alcohol. You had no 
emergent need for treatment and could have been treated in network. 
 
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 payment for the inpatient rehabilitation facility (IRF) services provided from April 20, 2023, to 
May 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 16, 2023. 
 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 the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I46.2, described as 
cardiac arrest due to underlying cardiac condition. This code is not an appropriate primary diagnosis as the 
code has a code first note indicating to code the underlying condition first. Based on this information, we 
decided that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on July 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 12, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
July 12, 2023.
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 the enrollee needs this care. The Plan denied your 
request. The Plan says medical records do not support the need for an IRF admission and, the enrollee needs 
can be provided at another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 16, 2022, to 
October 14, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 17, 2022. The NOA was not received by the Plan until May 11, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 16, 2022, to October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 7, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
receiver. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM receiver. You say that the enrollee is diagnosed with 
diabetes mellitus and needs the requested receiver. The Plan denied your request. The Plan says the enrollee 
does not use insulin and does not have a history of problematic hypoglycemia; therefore, she does not meet 
criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 CGM receiver have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) receiver.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 9, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee was inpatient for this date 
of service. This means the ambulance services are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided 
that the Plan does not have to pay for the ambulance services provided on July 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve cardiac ablation. 
 
You asked the Plan to pre-approve cardiac ablation. You say that the procedure will be a more definitive long-
term approach and hopefully allow the enrollee to stop metoprolol post-ablation. The Plan denied your request. 
The Plan says that the clinical records reviewed do not support the level of intervention the ablation procedure 
would provide. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac ablation. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that clinical studies have supported the role of catheter ablation for the treatment of 
supraventricular tachycardia (SVT) as an acceptable first-line alternative to medications in the treatment of 
patients with this arrhythmia. This is, in part, because of the high likelihood of success, without recurrences, 
compared with catheter ablation of atrial fibrillation, for example. Clinical guidelines have been modified to 
reflect the findings of these new studies. Therefore, electrophysiologic evaluation and catheter ablation of SVT 
would be considered reasonable in this 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 cardiac ablation have been met. Therefore, we decided that the Plan has to pre-
approve cardiac ablation.  
 
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.