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

 
We decided that the Plan does not have to pre-approve a cystourethroscopy, with insertion of a temporary 
prostatic implant/stent (C9769). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that further studies are needed to evaluate the durability of temporary implantable nitinol device (iTIND) 
outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate the 
advantages of a second-generation device over the first device.  This service is not recommended in the most recent American Urology Association (AUA) Guidelines 
regarding treatment of benign prostatic hyperplasia (BPH). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cystourethroscopy, with insertion of a temporary prostatic implant/stent (C9769).
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 an LTACH level of 
care and is stable for discharge to that level of care. The Plan denied your request. The Plan says the requested 
LTACH services do not meet the requirements for approval. 
 
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 all medically necessary care is being provided in the current acute care setting.  
 
 There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the self-administered drug 
Butalbital/Acetaminophen/Caffeine with Codeine Capsules. 
 
You asked the Plan to pre-approve Butalbital/Acetaminophen/Caffeine with Codeine Capsules. The Plan 
denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drug 
Butalbital/Acetaminophen/Caffeine with Codeine Capsules. 
  
Benefits for Butalbital/Acetaminophen/Caffeine with Codeine Capsules. 
 may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further 
information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is necessary for the enrollee to 
improve strength and endurance. The Plan denied your request. The Plan says the requested IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an ophthalmologist office visit. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for OON services 
have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64445 and 64450 billed for date of service 
June 15, 2022. 
 You asked the Plan to pay for procedure codes 64445 and 64450. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for codes 64445 and 64450 are bundled into 
payment for codes 28234 and 64704. 
 
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 64445 
is a column II code to column I code 28234. We have also confirmed that code 64450 is a column II code to 
column I code 64704. This claim has not been billed with an appropriate modifier to bypass the edit. 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 codes 64445 and 64450 billed for date of service June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you have a hard time moving the 
enrollee around on the semi-electric bed. The Plan denied your request. The Plan says a total electric hospital 
bed is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT 648 Solid Tumor Assay (81455) provided on 
November 19, 2022. 
 
You asked the Plan to pay for the Tempus xT 648 Solid Tumor Assay. You say that this test was medically 
necessary. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the Tempus xT 648 Solid Tumor Assay have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT 648 Solid 
Tumor Assay (81455) provided on November 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila (Q5108). 
 
You asked the Plan to pre-approve Fulphila. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested use of this drug is not approved by the 
FDA for the enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Fulphila. Our reviewer says that the 
requested use of Fulphila is not medically necessary. Our physician reviewer found the requested use of 
Fulphila is not approved by the Food and Drug Administration (FDA) for the enrollees diagnosis. The 
reviewer found that the requested use is not supported by one of the major drug compendia or by clinical 
research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of Fulphila is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila (Q5108).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 11, 2022, 
to October 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that *** The Plan denied your 
request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 11, 2022, to 
October 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a footplate extension component (K0108). 
 
You asked the Plan to pre-approve a footplate extension component. The Plan denied your request. The Plan 
says this is incorrectly coded and unbundled. The Plan also says this item still does not meet the coverage 
criteria. 
 
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 footplate extension component. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found foot plates have a specific code and should not be coded as K0108. Our 
reviewer also found that no clinical data is provided from vendor or health provider indicating the foot plate 
extension is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a footplate extension component have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a footplate extension component (K0108).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to bill 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 pay for the services provided on June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on 
November 25, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is excluded from coverage. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided on November 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 22, 2022. 
 
You asked the Plan to pay for the testing billed. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT 
code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a 
single unit of service. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on September 22, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes B4197, B4220, and B4224 billed for date of 
service May 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records show medical necessity. The 
Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes B4197, B4220, and B4224 were each billed with 3 units one a claim line. Each code 
has an MAI code of 1 and an MUE of 1. This means that only 1 unit may be billed for each claim line.  Based 
on this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes B4197, B4220, and B4224 billed 
for date of service May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast cancer index genetic testing (81518).  
You asked the Plan to pre-approve the genetic testing. You say that the breast cancer index test is medically 
necessary as it will provide information on the enrollee's benefit of extended use of anastrozole. The Plan 
denied your request. The Plan says this service is not medically necessary as the clinical information indicates 
the enrollee has positive nodes and her tumor is HER2 positive. 
 
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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are limited data as to the role of breast cancer index (BCI) in HR-positive, 
HER2-negative, and lymph node-positive breast cancer. This enrollee has both a HER2 positive and a node 
positive breast cancer and would not beet criteria for testing. The use of BCI would not be reasonable or 
medically 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the breast cancer index genetic testing (81518).
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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee continued stay at acute hospital until the enrollee is stable 
enough for discharge to a lower level of care has not been denied. 
 
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 is a 71-year-old who was admitted to the acute care hospital for a 
planned skin graft procedure for an abdominal wound complicated by infection and requiring antibiotics, drain 
placement, and debridements. Recent notes describe the patient is now using a fistula bag, is afebrile, without leukocytosis off antibiotics, stable on room air, and requiring only basic wound care.  
1. The enrollee appears to be improving with current treatment and should only require short-term additional 
acute care services that can safely be provided at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility.  
2. There are no services at the LTACH that the enrollee requires that are not already available and covered at 
the current facility.  
3. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. Completion of 
treatment at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A7046, A7038, A7032, A7039, A4604, and A7034 for 
date of service November 30, 2022. 
 You asked the Plan to pay for codes A7046, A7038, A7032, A7039, A4604, and A7034. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the claim was not billed with the 
appropriate modifiers. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes A7046, A7038, A7032, A7039, A4604, and A7034 are not supported in the medical 
record. Specifically, this claim was not billed with the appropriate modifier for coverage. Claim lines billed 
without a GA, GZ or KX modifier will be rejected as missing information. This means the claim is not payable 
as billed. Based on this information, we decided that Medicare rules for coverage of codes A7046, A7038, 
A7032, A7039, A4604, and A7034 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes A7046, A7038, A7032, A7039, A4604, and A7034 for date of service November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that the enrollee cannot manage the stairs. The Plan 
denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.