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

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic (L8702). 
 
You asked the Plan to pre-approve the MyoPro orthotic. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this item is considered experimental. 
 
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 MyoPro orthotic. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this 
patient's condition or in widespread use for this patient's condition based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient or that this device will increase participation in bimanual activities. 
 
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 MyoPro orthotic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoPro orthotic (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service February 
18, 2022. 
 
You asked the Plan to pay for procedure code(s) 88381. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88381. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88381. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service February 18, 
2022.
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 medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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 enrollees 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: 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 enrollee requires 3 hours of daily therapy, is on 
oxygen and needs assistance with most functions. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87631, 99072, and 94761, billed for date of 
service August 23, 2022. 
 
You asked the Plan to pay for procedure codes 87631, 99072, and 94761. The Plan denied your request. The 
Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted. Medicare rules also say that providers must report services 
correctly. Providers must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87631 have not been met 
 
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. We also find that code 94761 has a status indicator of T on the 
Physician Fee Schedule. As there were other payable services billed on this claim, code 94761 is considered 
bundled in this case. 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 87631, 99072, and 94761, billed for date of service August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 1, 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 November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery 
pressure monitor. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this is substantially proven and 
should be approved.  The Plan denied your request. The Plan says this remains experimental 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 the CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case.  Our physician reviewer found there remains a lack of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time, the CardioMEMS system would not be considered 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 the CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMS pulmonary artery pressure monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for dates of service February 
25, 2022, to March 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was treated for post-surgical 
inflammation. The Plan denied your request. The Plan says the documentation does not support treatment plans 
for lymphedema. 
 
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 claims for E0675 will be denied as not reasonable and necessary. Furthermore, the records 
provided do not show that the enrollee meets the coverage criteria for use of a PCD for the treatment of 
lymphedema. 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 code E0675 billed 
for dates of service February 25, 2022, to March 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve the endovenous ablation therapy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy may be covered when 
criteria listed in Medicare Rules section 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 the endovenous ablation therapy. Our 
reviewer says that the service is medically necessary. Our physician reviewer found there is satisfactory 
documentation that the patient has mobility limiting symptoms due to the venous reflux despite documented 
use of compression stockings for greater than 3 months. There is satisfactory documentation of absence of deep 
venous occlusion in the leg in question. There is documentation of satisfactory arterial perfusion to the lower 
extremities bilaterally. There is documentation that the portions of the vein to be treated are patent and free of 
thrombus that would inhibit passage of the catheter. 
 
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 endovenous ablation therapy have been met. Therefore, we decided that the 
Plan has to pre-approve the endovenous ablation therapy (36475).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is needed to prevent respiratory 
failure to support their breathing. It is also needed to prevent death and repeat hospitalization. The Plan denied 
your request. The Plan says a home ventilator is not medically necessary. The patient's needs can be met with a 
bilevel positive airway pressure (BiPAP) device with average volume-assured pressure support (AVAPS). 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the provided records in this 
case document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
However, the provided records document that the home ventilator is being requested for use in intelligent 
volume assured pressure support (IVAPS) mode with targeted tidal volume which could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. Provided records do 
not document trial and failure of a BiPAP device with AVAPS and a back-up rate. The provided records in this 
case do not provide adequate detailed information to meet Medicare criteria for coverage of a ventilator as 
opposed to a BiPAP device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 2, 2022, to March 
31, 2022. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. 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 2, 2022. The NOA was not received by the Plan until June 2, 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 on 
March 2, 2022, to March 31, 2022.
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 meets LTACH admission 
criteria, and their ongoing medical care warrants an LTACH level of care to achieve a safe and sustainable 
discharge.  The Plan denied your request. The Plan says the LTACH services requested 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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. 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: 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 the services are medically necessary for 
the enrollee's care needs. The Plan denied your request. The Plan says the enrollee's medical needs are being 
met in the current setting.  
 
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 appears to be still unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. 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 pre-approve a home ventilator, any type, used with noninvasive 
interface (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you need this device to help with breathing.  
The Plan denied your request. The Plan says the records do not show you have failed treatment with continuous 
positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) or that the requested noninvasive 
ventilator will not be used exclusively in CPAP or bi-level PAP mode.  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to chronic obstructive pulmonary disease (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 home ventilator. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found that provided records in this case 
document a diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. 
Provided records do not clarify that the ventilator is not being used exclusively in a BiPAP mode. The records 
in this case do not provide adequate detailed information to meet Medicare criteria for coverage.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator, any type, used with noninvasive interface (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Factor II (F2) and Factor V (F5) genetic analysis (81240, 
81241) provided on August 1, 2022. 
 
You asked the Plan to pay for F2 and F5 genetic testing. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered by Medicare as they are never 
considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 81240 and 81241 are unlikely to impact 
therapeutic decision-making in the clinical management of the patient and will be denied automatically as not 
medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 and F5 genetic testing have not been met. Specifically, these services are considered never 
medically necessary as they are unlikely to impact therapeutic decision-making in the clinical management of the patient. Therefore, we decided that the Plan does not have to pay for Factor II (F2) and Factor V (F5) 
genetic analysis (81240, 81241) provided on August 1, 2022.