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

 
We decided that the Plan does not have to pre-approve a non-invasive ventilator. 
 
You asked the Plan to pre-approve a non-invasive ventilator. You say that the enrollee has been on this device 
since July of 2020, and this is a continuation of care. You say that the enrollee cannot live without this. The 
Plan denied your request. The Plan says the requested device is not medically reasonable and necessary 
because it is being used as a bi-level positive airway pressure (BiPAP) device. 
 
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. 
 
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 non-invasive ventilator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  This enrollee has severe COPD and metastatic lung cancer, previously treated with 
surgical resection, chemotherapy, and radiation therapy.  The enrollee has been on a home ventilator at night 
since being hospitalized for an exacerbation in 2020.  Compliance is excellent.  There is no arterial blood gas 
(ABG) done while stable, to document chronic carbon dioxide (CO2) retention.  If that is present, the enrollee 
may benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep.  There is no 
documentation that this has been tried and failed as an outpatient. 
 
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 non-invasive ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a non-invasive ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis (L5981). 
 
You asked the Plan to pre-approve the lower extremity prosthesis. You say that you need the requested item in 
order to perform daily living activities. You say that the records provided support the need for the device in 
dispute. The Plan denied your request. The Plan says the signed physician order states that the enrollee is a K3 
ambulator, but that there are no medical records from the physician to show that the enrollee is a K3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for 
any item or service, the information submitted by the supplier or provider must corroborate the documentation 
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the lower extremity prosthesis. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical 
records provided give no details at all which might corroborate the request for L5981. The only clinical note 
provided is a wound care note from February 10, 2023, which gives no contextual details as to the enrollee's 
pre-morbid level of function or any exam of systems that would affect her present potential to return to 
unlimited community ambulation. 
 
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 lower extremity prosthesis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lower extremity prosthesis (L5981).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 17, 2021, to 
June 20, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code J96.01-Acute respiratory failure with hypoxia is the appropriate secondary diagnosis. The Plan 
denied your request. The Plan says the records submitted do not support secondary diagnosis code J96.01-
Acute respiratory failure with hypoxia. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01-Acute respiratory failure with hypoxia. 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 inpatient hospital services at the DRG 
originally billed. Our physician reviewer found the review of the medical record found no evidence of clinical 
symptoms or findings on physical exam consistent with a diagnosis of acute respiratory failure. The review has 
determined that the documentation did not support secondary diagnosis code J96.01-Acute respiratory failure 
with hypoxia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 17, 2021, to June 20, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (melanoma), gene expression profiling (GEP) 
(0089U) provided February 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please see attached appeal with documentation 
that supports medical necessity. The Plan denied your request. The Plan says Payment made according to 
Medicare allowable rate then auto forward. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found more evidence is needed to support using GEP testing to inform recommendations regarding 
sentinel lymph node biopsy (SLNB), intensity of follow-up or imaging surveillance, and postoperative adjuvant 
therapy. The literature recommends further research to assess the validity and clinical applicability of existing 
and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results 
should only be made in the context of discussion of testing limitations with the patient or within a 
multidisciplinary group. The review has determined that the items/services at issue in this case are 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for oncology (melanoma), gene expression profiling (GEP) (0089U) provided February 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99238 billed for September 2, 
2022, to September 5, 2022. 
 
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 procedure codes 99233 and 99238 are not supported. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
The definition of code 99238 is hospital discharge day management; 30 minutes or less 
 
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 these services. Our reviewer says that procedure codes 99233 
and 99238 are not supported. Our reviewer found the enrollee presented as a transfer on September 1, 2022 due 
to acute liver injury. He had a medical history including hypertension and hyperlipidemia. He had lactic 
acidosis and multiple liver lesions seen on computed tomography (CT) scan. The records do not support that 
there was a comprehensive history; therefore, code 99233 is not supported. 
 
The records do not support that hospital discharge day management of 30 minutes or less was performed to 
support code 99238. 
 
We looked at this coder's review, the file, and Medicare rules. 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 procedure codes 99233 and 99238 billed for September 2, 2022, to September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0241U provided on January 9, 2023. 
 
You asked the Plan to pay for procedure code 0241U. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 0241U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0241U 
provided on January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that proton beam therapy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is a scarcity of data regarding the 
use of proton beam therapy for the treatment of pancreatic cancer. The records do not support that proton beam 
therapy would decrease the probability of clinically meaningful normal tissue toxicity by lowering an integral 
dose-based metric and/or organ at risk dose volume constraint associated with toxicity. There is no 
documentation to support that the target volume is near one or more critical structures and a steep dose gradient 
outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s), which 
would portend a higher risk of toxicity. The criteria for coverage are not met and the services are not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara 130MG/26ML intravenous solution.  
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed two of the following drugs: 
adalimumab, Rinvoq or Xeljanz, Xeljanz XR. The Plan states failed means the enrollee did not tolerate the 
drugs, or the enrollee's symptoms did not get better. The Plan states the information from the enrollee's 
provider shows the enrollee did not meet criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the case file does not contain sufficient documentation to demonstrate that two of the Plan's required 
drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Stelara 130MG/26ML intravenous solution.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide care skilled services. 
 
You asked the Plan to pre-approve the aide services. You say that you would like to request reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are not medically reasonable and necessary. Our physician reviewer found the documentation 
does not support that the additional hours are needed to provide adequate support for the enrollee.  
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 aide services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide care skilled services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chest magnetic resonance imaging (MRI.) 
 
You asked the Plan to pre-approve a chest MRI. You say that the records provided support that a chest MRI is 
medically reasonable and necessary. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a chest MRI. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the records do not demonstrate that the 
enrollee has cardiopulmonary symptoms. The documentation does not support the rationale for this imaging 
study and the guidelines for coverage do not support a need for a chest MRI in this setting. A chest MRI is not 
medically appropriate and necessary 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 a chest MRI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chest magnetic resonance imaging (MRI.)
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
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 enrollee is minimal assist for upper body activities of daily living, transfer and 
ambulation in the setting of acute illness and advanced age. There is no evidence based on clinical practice 
standards supporting IRF for a person at minimal assist level and recovering from an acute illness. The 
enrollee's functional status does not warrant intensive rehabilitation services or frequent physiatry oversight. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botulinum toxins (Botox, Dysport, Xeomin and 
Myobloc), will be considered medically reasonable and necessary when administered for treatment of certain 
FDA-labeled indications and Off-label indications. 
 
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 Botox. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested Botox does not meet the coverage criteria as outlined in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on June 27, 2022, billed with 
codes 75726-26-XU, 75726-26-XU-76, 75774-26-XU, and 75774-26-XU-76. 
 You asked the Plan to pay for the imaging as billed. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says the codes at issue are not supported. 
 
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 75726 is a column II code to column I code 37243; however, 75726 
was billed with a modifier.  
 
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 imaging as billed. Our reviewer says that the 
documentation does not support payment for these codes. Our reviewer found the record shows that an 
interventional procedure was performed, and there is no evidence to support separate payment for the imaging 
described by 75726. Coding guidelines state that open and percutaneous interventional vascular procedures 
include operative angiograms and/or venograms which shall not be separately reported as diagnostic 
angiograms/venograms. This also applies to the services described by 75774. 
 
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 imaging as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the imaging services provided on June 27, 2022, billed with codes 75726-26-XU, 
75726-26-XU-76, 75774-26-XU, and 75774-26-XU-76.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left heart catheterization. 
 
You asked the Plan to pre-approve a left heart catheterization. You say that the records provided support the 
need for the services in dispute. The Plan denied your request. The Plan says there is no indication of ischemia 
as a cause for this enrollee's chest pain and she has been documented to have widely patent coronary arteries. 
The Plan says that a left heart catheterization is not medically necessary at this time. 
 
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 left heart catheterization. Our 
reviewer says that a left heart catheterization is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation does not reveal non-invasive evaluation such as stress test or 
coronary computed tomography (CT) imaging. Guidelines do not support a need for invasive cardiac catheterization in this setting. Cardiac catheterization 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 a left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a left heart catheterization.