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

 
We decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) gene analysis, CALR 
(calreticulin) gene analysis, JAK2 targeted sequence analysis, and MPL gene analysis. 
 
You asked the Plan to pre-approve JAK2 gene analysis, CALR gene analysis, JAK2 targeted sequence 
analysis, and MPL gene analysis.. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve JAK2 gene analysis, CALR gene 
analysis, JAK2 targeted sequence analysis, and MPL gene analysis. Our reviewer says that the documentation 
does not support that the requested testing is medically reasonable or necessary. Our physician reviewer found 
the enrollee has invasive ductal carcinoma of the right breast. There is no documentation of a bone marrow 
aspirate or BCD-ABL1 testing. The review has determined that the enrollee does not have a 
diagnosis/condition that meets criteria for the requested services. Therefore, the enrollee does not meet criteria 
for the requested testing.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of JAK2 gene analysis, CALR gene analysis, JAK2 targeted sequence analysis, 
and MPL gene analysis. have not been met. Therefore, we decided that the Plan does not have to pre-approve 
JAK2 (Janus kinase 2) gene analysis, CALR (calreticulin) gene analysis, JAK2 targeted sequence analysis, and 
MPL gene analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluid-circulating cold pad with pump (E0218) billed for 
dates of service March 9, 2023, to March 28, 2023. 
 
You asked the Plan to pay for code E0218. You say that this item is medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  The item at issue here is a non-covered fluid circulating cold 
pad with pump (E0218). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0218 have not been met. Therefore, we decided that the Plan does not have to pay for the 
fluid-circulating cold pad with pump (E0218) billed for dates of service March 9, 2023, to March 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on February 
14, 2022. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these claims are missing necessary ZIP Codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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, the claims at issue are ambulance claims, but 
the ZIP Code of the point of pickup has not been reported on either claim. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0428, A0425) provided on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L4-L5 lumbar laminectomy with total posterior 
arthroplasty system (TOPS). 
 
You asked the Plan to pre-approve L4-L5 lumbar laminectomy with TOPS. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the clinical value and effectiveness of 
this procedure in the setting of lumbar spondylolisthesis have not been demonstrated. 
 
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 L4-L5 lumbar laminectomy with TOPS. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the provided lumbar X-Rays demonstrated the lordosis is preserved. 
The enrollee's height is 68 inches and weight is 157 pounds. There are no bone density exams provided to corroborate a lumbar spine T-score of less than -2.0. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical 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 L4-L5 lumbar laminectomy with TOPS have not been met. Therefore, we 
decided that the Plan does not have to pre-approve L4-L5 lumbar laminectomy with total posterior arthroplasty 
system (TOPS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whirlpool, non-portable (built-in type). 
 
You asked the Plan to pre-approve the whirlpool. You say that this is medically necessary. The Plan denied 
your request. The Plan says you are not homebound, and are doing well with physical therapy. 
 
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 whirlpool. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are not homebound. You can participate in land-based and aquatic therapy programs for 
chronic low back pain and lumbar spinal stenosis. Given that you have access to aquatic therapy, there is a lack 
of documentation indicating that the requested swim spa will provide a therapeutic benefit that is more 
significant than what you are already receiving. 
 
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 whirlpool have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a whirlpool, non-portable (built-in type).
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 admission to the LTACH is medically 
necessary. You would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says admission to an LTACH is not medically necessary.  
 
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 had a tracheostomy (history of prior tracheostomy) and also required 
left above knee amputation because of intractable pain. The enrollee has a PEG in place. The enrollees oxygen 
requirements are 35% FIO2 trach mask. The team is still working on pain control. It seems unlikely that the enrollee will need an additional 25 days of hospitalization. No therapeutic benefit to transfer to an LTACH is 
anticipated. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) 
provided from March 15, 2022, to April 21, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that the services were medically necessary. 
You also say that they should be paid. The Plan denied your request. The Plan says this service is considered 
experimental and therefore is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the fluoroscopic guidance. Our reviewer 
says that the fluoroscopic guidance was not considered medically reasonable and necessary in this case. Our 
physician reviewer found knee injections are typically not guided by fluoroscopy as manual identification of 
anatomy markers are sufficient in the average patient. There was no report in the documentation that the 
identification of the enrollee's anatomy was challenging to justify using fluoroscopy. Therefore, the request 
for the fluoroscopic guidance for needle placement (77002) provided on the dates of service in this case were 
not 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 the fluoroscopic guidance have not been met. Therefore, we decided that the 
Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided from March 15, 
2022, to April 21, 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 would benefit from a 
LTACH admission for their wound care needs. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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.  
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliances (E0652, 
E0656, E0667). 
 
You asked the Plan to pre-approve the pneumatic compression device and appliances. You say that this item 
was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and appliances (E0652, E0656, E0667).
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 requires LTACH services to 
regain their prior level of functioning. The Plan denied your request. The Plan says the request is not medically 
necessary. 
 
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.  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 24, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 24, 2023.
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 exceeds the criteria for 
admission to an LTACH, and you would like reconsideration based on the records submitted. The Plan denied 
your request. The Plan says the request for admission to an LTACH does 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 need daily physician visits at this time, nor 6.5 hours of 
daily nursing care. The enrollee's needs can be managed at a lower level of care once they are ready for discharge.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of October 21, 
2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee's care can be safely provided in another 
setting such as residential, partial hospitalization program, or outpatient care. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for continued inpatient psychiatric care. Our physician reviewer 
found it is not expected that the enrollee will improve in a reasonable period of time beyond the dates in 
question as the enrollee was not showing any dangerousness to self or others, auditory or visual hallucinations, 
or aggressive behaviors while not showing any acute threats of safety. It does not appear medically reasonable 
and necessary to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of October 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 You asked the Plan to pre-approve the requested device. You say that the device is designed to treat the 
enrollee's medical condition. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee was being treated for 
lymphedema extending onto the chest, trunk, or abdomen. The documentation does not show that the basic 
pump was tried for four weeks. Furthermore, the medical records are from December 2022. There are no 
current medical records provided to show that the enrollee is still being treated for lymphedema and that a 
pneumatic compression device is still needed. Based on this information, we decided that Medicare rules for 
coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-
approve a pneumatic compression device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 21, 2023, to 
May 27, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim was billed with an incorrect bill type. 
 
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 type of bill was incorrect. The type of bill on the 
claim was 323. The home health claim should be billed with type of bill 0329. 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 May 21, 2023, to May 27, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cimerli. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that step therapy requirements have not been 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 the medication. Our reviewer says that 
the criteria for coverage of Cimerli have not been met. Our physician reviewer found that the Plan requires a 
trial of bevacizumab before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug. There is no documentation provided indicating that the Plan's required drug would 
likely be less effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Cimerli.