Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Nodify CDT testing (81599) provided on September 10, 2022. 
 
You asked the Plan to pay for Nodify CDT testing. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that 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 shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Nodify CDT testing have 
been met. Therefore, we decided that the Plan has to pay for Nodify CDT testing (81599) provided on 
September 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0676).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty procedure (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that a total knee arthroplasty is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 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 a total knee arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative-care measures is not evident in the case record. Such measures 
include any viscosupplementation injections and physical therapy failure. Although the enrollee has recently started to attend physical therapy, there has not been a failure of a complete course. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in the enrollee's clinical 
setting. No compelling rationale is presented nor extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty procedure (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic knee for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve an electronic knee. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not separately reimburse for 
repairs of items covered under a manufacturers or suppliers warranty. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an electronic knee have not been met. Specifically, the Plan has attested that the enrollee's current durable medical equipment is still under warranty. Therefore, we decided that the Plan does not have to pre-
approve an electronic knee for a lower-limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51702 billed for date of service September 8, 
2022. 
 You asked the Plan to pay for procedure code 51702. You say that the services were provided in good faith. 
The Plan denied your request. The Plan says payment for code 51702 is bundled into payment for code 10060. 
 
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 51702 is a column II code to column I code 10060. CPT code 51702 
has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
51702 billed for date of service September 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an X-Stop device. 
 
You asked the Plan to pre-approve an X-Stop device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 an X-Stop device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the xstop device is experimental. High failure rates have been reported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an X-Stop device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an X-Stop device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2042 billed for date of service October 1, 
2022, to October 31, 2022. 
 
You asked the Plan to pay for procedure code T2042. You say that the code is valid for home hospice. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code T2042 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2042 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2042 billed for date of service October 1, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care (11042) provided on November 29, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that only when medical necessity continues to be met and 
there is documented evidence of clear benefit from the debridements already provided, should debridement 
services be continued beyond eight 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 pay for the services. Our reviewer says that the requested wound care services were not medically reasonable and necessary. Our physician reviewer found that 
the enrollee had been receiving wound care with debridement and had received eight visits prior to the visit 
November 29, 2022. There was no specific indication of clear benefit from continued debridements beyond the 
recommended eight total surgical excisional debridements. Per the documentation, the wound had 60% 
granulation. The debridement services provided on November 29, 2022, were 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the wound care (11042) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of internal fixation devices (e.g., pin, rod), other 
procedures on the dentoalveolar structures (extraction of teeth) and an alveoloplasty provided on  
September 22, 2021. 
 
You asked the Plan to pay for removal of internal fixation devices (e.g., pin, rod), other procedures on the 
dentoalveolar structures (extraction of teeth) and an alveoloplasty. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services are dental in nature and cannot be covered 
under the medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for removal of internal fixation 
devices (e.g., pin, rod), other procedures on the dentoalveolar structures (extraction of teeth) and an 
alveoloplasty provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 2, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
March 1, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 3, 2022, to 
March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on December 31, 2022. 
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the supplies are only 
covered one monthly. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted proof 
of delivery shows a delivery date of December 23, 2022. This date does not match the date of service in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the supplies provided on December 31, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical procedures on arteries and veins, endovascular 
revascularization. 
 
You asked the Plan to pre-approve surgical procedures on arteries and veins, endovascular revascularization. 
You say that surgical procedures on arteries and veins, endovascular revascularization is medically necessary 
The Plan denied your request. The Plan says surgical procedures on arteries and veins, endovascular 
revascularization 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 surgical procedures on arteries and 
veins, endovascular revascularization. Our reviewer says that the requested surgical procedures on arteries and 
veins, endovascular revascularization is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no evidence of limb threat and no evidence of significant lower extremity 
arterial occlusive disease proximal to the tibial arteries. The enrollee has diabetes and is status post bilateral 
peroneal artery interventions suggesting that the anterior tibial and posterior tibial artery occlusions are chronic.  
Studies immediately following the previous interventions are not provided. The documentation that is provided 
suggests the enrollees post intervention walking distance was two blocks, supporting alternative etiologies for 
his walking limitation. In general, it is not advisable to intervene on tibial arteries in the absence of limb threat 
as such intervention could do more harm than good. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical procedures on arteries and veins, endovascular revascularization have 
not been met. Therefore, we decided that the Plan does not have to pre-approve surgical procedures on arteries 
and veins, endovascular revascularization.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve ablation of a malignant prostate tissue with high-intensity focused 
ultrasound (HIFU). 
 
You asked the Plan to pre-approve ablation of a malignant prostate tissue with HIFU. You say that the services 
are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 ablation of a malignant prostate tissue 
with HIFU. Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found HIFU is medically reasonable and necessary in this case. 
HIFU treatment of the prostate is neither experimental nor investigational. HIFU was FDA approved for 
prostate gland ablation October 9, 2015. HIFU of the prostate has Medicare coverage as of July 1, 2017. More 
than 100 clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but 
with a much lower risk of side effects such as impotence, incontinence and bowel injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ablation of a malignant prostate tissue with HIFU have been met. Therefore, we 
decided that the Plan has to pre-approve ablation of a malignant prostate tissue with high-intensity focused 
ultrasound (HIFU).  
 
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 pay for the pneumatic compression device provided on November 
23, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on November 23, 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. You say that it is medically necessary. The Plan denied your 
request. The Plan says you 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a 
lower extremity leg wound and was transferred to skilled nursing on March 10th, 2023, and was discharged 
from physical therapy on May 8th, 2023 because of a lack of functional progress. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program.  
 
There is not a reasonable expectation that this patient 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 acute inpatient rehabilitation facility (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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 clinical documentation does not specify any complex functional impairments 
(debility) or active medical comorbidities (no significant progressive macular hypomelanosis, medically stable 
in SNF setting) thus the complexity of the enrollees documented nursing, medical and rehabilitation needs 
would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. 
 
Clinical documentation shows that the enrollee requires ongoing physical and occupational therapy, however 
there is no documentation that supports an intensive rehabilitation regimen in an IRF setting. Additionally, 
there is no documentation to show that patient would tolerate an intensive rehabilitation regimen.  
 
IRF criteria not met. 
 
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.