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

 
We decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340) 
with transesophageal echocardiogram (93312). 
 
You asked the Plan to pre-approve LAAC with transesophageal echocardiogram. You say that this is medically 
necessary. The Plan denied your request. The Plan says the request is not medically necessary because the 
records do not show documentation of shared decision making by an independent non-interventional physician. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC is covered when specific criteria are met, such 
as if there is a formal shared decision-making interaction with an independent non-interventional physician 
using an evidence-based decision tool. 
 
   
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 LAAC with transesophageal 
echocardiogram. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
while there is reference to consideration of the LAAC, there is no documentation of performance of an 
evidence-based shared decision-making interaction on anticoagulation. As such, guidelines would not support 
implantation of a LAAC in this 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 LAAC with transesophageal echocardiogram have not been met. Therefore, we 
decided that the Plan does not have to pre-approve left atrial appendage closure device (LAAC) (33340) with 
transesophageal echocardiogram (93312).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee is at a high risk for hospital 
readmission and potentially life-threatening exacerbations. The Plan denied your request. The Plan says the 
request is not medically necessary because the records show that the ordered settings for the noninvasive 
ventilator show it is going to be used only in a bi-level pressure mode. 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has multiple 
comorbidities contributing to his chronic respiratory failure. He also has alcohol abuse and Klonipin use which 
will exacerbate his chronic hypercapnia. BIPAP therapy has been successful at treatment of his chronic 
respiratory failure, but the enrollee is noncompliant. There is no documented failure of BIPAP or BIPAP with 
average volume assured pressure support (AVAPS). The enrollee would likely benefit from continued 
compliance. However, there is no best practice evidence to recommend home ventilator at this time given 
documentation provided. Hence, no home ventilator. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 the LTACH services. You say that the enrollee requires LTACH care to 
regain and maintain maximum function. The Plan denied your request. The Plan says admission to an LTACH 
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 there are no required medical services identified that are available at the LTACH that 
are not available at the current health care setting being offered by the Plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug system (A4304) and supplies (A4221, 
A4223). 
 
You asked the Plan to pay for the disposable drug system and supplies. You say that the items should be 
covered. The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. Drugs and supplies used with disposable drug delivery 
systems are also non-covered items. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug system and supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for the disposable drug system (A4304) and supplies (A4221, A4223).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract removal services provided on December 7, 2022. 
 
You asked the Plan to pay for cataract removal services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not covered when provided by a non-
Medicare enrolled provider. 
 
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 pay for cataract removal services provided on 
December 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for codes 87502 and 87798 for date of service March 27, 2023. 
 
You asked the Plan to pay for codes 87502 and 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that incorrect billing has been identified. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan states that incorrect billing has been 
identified. The Plan states that it was determined that the individual CPT code is an integral part of a panel CPT 
code 87633, which is described as an infectious agent detection by nucleic acid (DNA or RNA); respiratory 
virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory 
syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified 
probe technique, multiple types, or subtypes, 12-25 targets). However, the documentation does not show that 
code 87633 was billed on this claim. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for codes 87502 and 87798 for date of service March 27, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TriVisc.  
 
You asked the Plan to pre-approve TriVisc. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the records do not show that the enrollee's past 
injection with the same drug gave them significant improvement in their pain and function.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 TriVisc. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that the degree of pain relief and the 
increase in range of motion does not meet the Local Coverage Determinations (LCD) criteria.  Therefore, the 
request is deemed 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 TriVisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TriVisc.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0427) and ground mileage (A0425) 
provided on April 24, 2023. 
 
You asked the Plan to pay for the ambulance service and mileage. You say that you are appealing the denial 
with supporting documentation. 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 M62.81 has an Excludes1 note in relation to M79.10. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the ambulance service and mileage have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service (A0427) and ground mileage (A0425) provided on April 24, 
2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 requires IRF services to regain as much 
of their prior level of functioning as possible and improve their quality of life. The Plan denied your request. 
The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The medical record supports a need for 
physical and occupational therapy. Additionally, there a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: 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 all recommendations are for IRF care. The Plan 
denied your request. The Plan says the denial of IRF care is correct.  
 
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 can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are still in the hospital and need rehab as soon 
as possible.  The Plan denied your request. The Plan says a SNF admission is not medically necessary.   
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 the LTACH services. You say that the enrollee has issues that can't be 
managed at a lower level of care and requires daily physician management. The Plan denied your request. The 
Plan says the LTACH services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving appropriate care in the current acute care setting being 
provided by the health Plan. The documentation does not support that LTACH services are medically 
appropriate at this 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 home health skilled nursing visits  
 You asked the Plan to pre-approve 16 home health skilled nursing visits. You say that the clinical provided 
showed that the denied code was a part of the member's treatment plan and believed the request should be 
approved. The Plan denied your request. The Plan says 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 16 home health skilled nursing visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
Based on the limited documentation provided the enrollee does not have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 16 home health skilled nursing visits
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 22, 2022, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, and 
81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. The 
Plan also says that you billed these services using the wrong POS code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. In addition, 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. You 
billed this service using the POS code of 81, but the patient encounter did not occur in a lab setting. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 22, 2022, 
billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191, and 
81309.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein 
(36482). 
 
You asked the Plan to pre-approve endovenous ablation. You say that the procedure is medically necessary. 
The Plan denied your request. The Plan says endovenous ablation is not medically necessary. The enrollee does 
not meet criteria due to no evidence of conservative therapy trial and failure. 
 
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 endovenous ablation. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found coverage criteria require that the symptoms be attributable to the veins in question.  
The enrollee complains of bilateral lower extremity symptoms and part of the plan is to ablate the left greater 
saphenous vein even though there is no reflux throughout essentially the entirety of the left great saphenous 
vein. With regard to the right side, the vein is diminutive along its majority length; the reflux is intermittent, 
and there is no reflux in the lower leg. There is a description in the medical record that the enrollee is 
experiencing mild aching at her ankles. There is no reflux in this territory in either leg. The enrollee is status 
post what is described as four knee replacements. Therefore, it is very possible that leg symptoms that may be 
impacting activity could be related to other sources. As the documentation does not satisfactorily demonstrate 
that the enrollee is having activity limiting symptoms attributable to the veins in question, the reviewer is 
unable to overturn the health plan determination. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation therapy of incompetent vein (36482).