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

 
We decided that the Plan does not have to pay for procedure code 99309 rendered on May 10, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99309 25 (1 Unit ) remains 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. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99309 as there is no clear documentation that the encounter required medical 
decision-making moderate complexity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99309 rendered on May 10, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued skilled nursing facility (SNF) care provided 
from February 3, 2023, to March 4, 2023. 
 You asked the Plan to pay for the continued SNF care. You say that the continued SNF care should be paid for 
under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for 
continued SNF care. 
 
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 pay for 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 the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 pay for the continued skilled nursing facility (SNF) care provided from February 3, 2023, to March 4, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve prosthetic parts (L5910, L5968, L5972). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested prosthetic parts do not meet Medicare criteria for being reasonable 
and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that one of the criteria that is sufficient for replacement of a prosthesis/component is a change in the 
physiological condition of the beneficiary. Meanwhile, the medical record provided, like the certified 
prosthetist/orthotist (CPO) clinic note from March, appeal letter from August, and the physician note from 
April, establish that such physiological changes have occurred, most notably that her functional level has 
advanced since her rehab and provision of her initial prosthesis after amputation, as is to be expected. 
Therefore, replacement of the previous K2 foot, whose warranty cannot make it functional for this enrollee, is 
reasonable and necessary. 
 
Additionally, the medical record also establishes the enrollee's K3 activity level potential. While the question 
regarding the originally requested K3 microprocessor foot is not the topic of this review, her functional 
potential even more so qualifies her for the hydraulic foot being requested now, under LCD L33787.  
 
Given all of the above, it is highly likely that traditional Medicare would have covered the original foot 
requested by the treating team, but, in any event, the less sophisticated foot/alignable system now being 
requested is even less controversial and is also reasonable and necessary for this 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 services have been met. Therefore, we decided that the Plan has to pre-
approve prosthetic parts (L5910, L5968, L5972).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace (22612). 
 
You asked the Plan to pre-approve the Minuteman device. You say that you are requesting reconsideration 
because the enrollee is in debilitating pain. The Plan denied your request. The Plan says the device is not 
medically necessary until its efficacy has been established. 
 
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 Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Minuteman device is experimental and investigational. There is more research 
needed due to insufficient efficacy. 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace (22612).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428-QL) provided on April 18, 2023. 
 You asked the Plan to pay for ambulance services. You say that no ZIP Code may be reported as the enrollee 
was pronounced dead at the scene, so there was no official point of pick-up. The Plan denied your request. The 
Plan says this claim is missing the necessary ZIP code to accurately determine Medicare payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that the ZIP Code of the point of pickup must be reported on each claim for ambulance services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance services have not been met. Specifically, no ZIP Code was reported in item 23 on the 
CMS-1500 claim form. Although these services were billed with modifier -QL, indicating the enrollee was 
pronounced dead after the ambulance was called but before being loaded for transport, there is no indication 
that the ZIP Code would is not required in that case. This information is necessary to determine the correct 
payment rate and any adjustments for services rendered. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0428-QL) provided on April 18, 2023.
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 appeal 
of the LTACH denial. The Plan denied your request. The Plan says criteria for admission to the LTACH have 
not been met. 
 
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 not stable and requires additional short-term acute care services until 
more stable and appropriate for transfer. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the CardioMEMs device has not been 
demonstrated in the peer-reviewed literature. 
 
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 device. 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 Food and Drug Administration (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 congestive heart failure (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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (87801) provided on March 22, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the billing of this service does not meet the coding 
standards. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted without ICD-10 diagnosis 
codes to support medical necessity will be denied as not medically necessary.  
 
We looked at the file and Medicare rules. The record shows that the diagnosis codes billed on this claim do not 
support the medical necessity of procedure code 87801. Based on this information, we decided that Medicare 
rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (87801) provided on March 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VivAer procedure. 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this procedure 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 the VivAer procedure. Our reviewer 
says that the requested VivAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has nasal sinus disorder with nasal 
obstruction. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions. The record provided does not establish the medical necessity and reasonableness, 
as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. Therefore, the reviewer found that the requested VivAer procedure 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 the VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve VivAer procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82947) provided on February 27, 
2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says these services are not payable as they were provided by a 
VA facility or military hospital. 
 
The Plan must follow Medicare rules. Medicare rules say that VA facilities and military hospitals are excluded 
from participating in Medicare. The rules also say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 We looked at the file and Medicare rules. The provider in this case is not enrolled in or is not eligible to enroll 
in the Medicare program. Based on this information, we decided that Medicare rules for coverage of laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(82947) provided on February 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the medication. You say that given the rarity of this disease there are no 
preferred or standard treatment regimens. The enrollee is having significant disease progression and is 
becoming more symptomatic. The Plan denied your request. The Plan says the requested treatment order of 
Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the medication. Our reviewer says that 
that the requested use of Keytruda is not FDA approved for the enrollees diagnosis. Our physician reviewer 
found that the use of Keytruda is also not supported by one of the major drug compendia or by clinical 
research. 
 
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 Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81257). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover genetic testing if the genetic 
test has been approved following a technical assessment by MolDx. 
 
We looked at the file and Medicare rules. The requested test (Alpha-Globin Common Mutation Analysis) is not 
listed as an approved test by MolDx. 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 genetic 
testing (81257).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 25, 2022, to May 
4, 2022. 
 You asked the Plan to pay for the home health services. You say that you think the claim payment should just 
be reduced, not denied in full. The Plan denied your request. The Plan says the NOA was not received timely. 
As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 21, 2022. The NOA was not received by the Plan until May 11, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 25, 2022, to May 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
15, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are not enrolled with Medicare but medical 
records have been provided. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 24, 2023, billed with 
procedure code 99212-AI. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says this service is bundled into payment of 
anesthesia code 01480. 
 
The Plan must follow Medicare rules. Medicare rules say that postoperative evaluation is included in the base 
unit for the anesthesia service. 
 
We looked at the file and Medicare rules. We have confirmed that this code is not payable as it is related to code 01480 provided on March 23, 2023. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met.  Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on March 24, 2023, billed with procedure code 99212-AI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on November 12, 2022. 
 
You asked the Plan to pay for the walker. You say that you are requesting reconsideration of the denied item. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the walker provided on 
November 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 25, 2022. 
 
You asked the Plan to pay for the home health services. You say that the provider is eligible for reimbursement 
for the full billing period even if the patient did not receive home health services on the same day as an 
inpatient stay. The Plan denied your request. The Plan says no records were provided to support the Health 
Insurance Prospective Payment System (HIPPS) code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services have been 
met. Specifically, you have failed to supply any medical records that would support the billing of the HIPPS 
code on the claim.  Without records, we cannot determine if the services rendered were billable. Therefore, we 
decided that the Plan does not have to pay for home health services provided on May 25, 2022.