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

 
We decided that the Plan does not have to pre-approve a cystourethoscopy. 
 
You asked the Plan to pre-approve cystourethoscopy. You say that your condition is unresolved and the next 
course of action is removal of the stent. The Plan denied your request. The Plan says this 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 cystourethoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you have a urethral stent that requires removal. The removal 
of the stent is medically necessary and recommended. However, the record does not document a medical 
reason why the stent must be removed under anesthesia.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cystourethoscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a cystourethoscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen intravenous immune globulin (IVIG). 
 
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 IVIG 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 the enrollee has unspecified 
polyneuropathy. The record provided does not establish that the enrollee has a diagnosis for which coverage is available per the Medicare criteria. The services are therefore 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 Privigen intravenous immune globulin (IVIG).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for November 22, 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 code 99153 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 

We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 code 99153 billed 
for November 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on March 17, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the services provided are not payable. 
 
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 has overturned all dates of drug testing 
except March 17, 2022. The documentation provided only provided an explanation on why the services that are 
being covered should be covered. The documentation did not include explanation of why this date of service is 
not covered. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the drug testing provided on March 17, 2022.  
 
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 Feraheme. 
 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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia. 
He has not tried and failed the Plans' required drugs, Infed and Venofer. The records do not show that the 
required drugs would be contraindicated or less effective; therefore, Feraheme is not 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested system is to 
wirelessly measure and remote monitor pulmonary artery) pressure. This is a necessary therapy for the 
treatment plan on this enrollee due to unnecessary hospitalizations and excessive contact to manage her chronic 
congestion, CHF exacerbations, and medication compliance/ adjustments. The Plan denied your request. The 
Plan says the CardioMEMS device has been determined to be of uncertain value in the most recent 2022 
ACC/AHA Guidelines and carries a risk of significant complications including death and severe pulmonary 
artery injury. 
 
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 CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollees 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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289, C2624).
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says the 
enrollee does not meet the guidelines for care in an LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical 
clearance to undergo this elective procedure. The Plan states the planned procedure listed under codes 22633, 
22840, 22853, 20931, 20930, 61783, 63047, are not listed on the Centers for Medicare & Medicaid Services 
(CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure and 
there is no documentation provided to support the expectation the enrollee will require a greater than two (2) 
midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical 
information. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record indicates that the enrollee is scheduled for transforaminal lumbar 
interbody fusion L1-L2. The record provided does not indicate that the medical condition, safety, or health of 
the enrollee would be significantly and directly threatened if care was provided in a less intensive setting. The 
initial day may be spent in observation until it is clearly expected that an inpatient stay would be required, at 
which time the physician may order inpatient admission. 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 28, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records did not 
include a valid physician order/lab requisition. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The submitted documentation only contain lab results from the drug 
testing. A valid physician order or lab requisition was not provided. The documentation does not contain 
medical records showing the ordering physicians intent that the testing be performed. 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 the drug testing services provided on March 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
nearly at their baseline level of mobility and only requires supervision for mobility with the assistance of a 
walker. The enrollee may require some degree of supervision for safety, but they do not require the services of 
a skilled physical therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed tomographic (CT) colonography, 
diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if 
performed (74262). 
 
You asked the Plan to pre-approve a Computed tomographic (CT) colonography, diagnostic, including image 
postprocessing; with contrast material(s) including non-contrast images, if performed (74262). The Plan denied 
your request. The Plan says the request cannot be approved this for colon cancer screening as this test was done 
in 2021 and medical policy states this must not have had one in the past five years. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 Computed tomographic (CT) 
colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast 
images, if performed (74262). Our reviewer says that the service is not medically necessary. Our physician 
reviewer found no records were provided that the enrollee is absolutely contraindicated to optical colonoscopy. 
 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 Computed tomographic (CT) colonography, diagnostic, including image 
postprocessing; with contrast material(s) including non-contrast images, if performed (74262) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Computed tomographic (CT) 
colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast 
images, if performed (74262).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99072 and 94761 billed for date of service 
September 27, 2022. 
 
You asked the Plan to pay for procedure codes 99072 and 94761. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 99072 and 94761 are 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that codes billed with a status indicator of B are 
considered bundled and not separately payable. Codes billed with a status indicator of T are only separately 
payable if no other payable codes are billed on the same date of service. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. In addition, procedure code 94761 has a status indicator of T. 
This code was billed on the same claim by the same provider on the same date of service as other codes that 
have been paid. This means that procedure code 94761 is also not separately payable. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99072 and 94761 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99072 and 94761 billed for 
date of service September 27, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
require frequent reassessments by a rehabilitation doctor for changing rehab needs. 
 
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 needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2313, E2377) and 
the power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and power seat elevation feature. You say that the 
requested items are medically necessary. The Plan denied your request. The Plan says that the upgraded 
electronics and power seat elevation are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that upgraded electronics are covered when it is medically 
necessary to control the power options through the joystick. The rules also say that a power seat elevation 
feature is not primarily medical in nature. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has adequate 
capacity to manage the standard power drives on the Group 3 power wheelchair. The request is not necessary to 
meet the enrollee's 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 the upgraded electronics have not been met. A power seat elevation feature is 
not covered as it does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-
approve the upgraded electronics (E2311, E2313, E2377) and the power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 14, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on October 14, 2022.