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

 
We decided that the Plan does not have to pre-approve Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that Rituxan is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Rituximab in combination with methotrexate is 
indicated for the treatment of adult patients with moderately- to severely- active rheumatoid arthritis who have 
had an inadequate response to one or more Tumor Necrosis Factor (TNF) antagonist therapies. 
 
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 Rituxan. Our reviewer says that 
Rituxan is not medically necessary. Our physician reviewer found the records do not show that the Rituxan is 
being given with Methotrexate. The records show no reason that methotrexate would be unsafe or ineffective 
for this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wound suction, disposable, includes dressing, all 
accessories and components, any type, each (A9272). 
 
You asked the Plan to pre-approve wound suction. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the information received did not meet the rules 
established by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable wound suction pumps and related 
supplies (A9272) will be denied as statutorily noncovered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wound suction have not been met. Specifically, Disposable wound suction pumps and related 
supplies (A9272) are not a covered benefit with the Plan. Therefore, we decided that the Plan does not have to 
pre-approve wound suction, disposable, includes dressing, all accessories and components, any type, each 
(A9272).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to stay in the skilled nursing 
facility for continuous around the clock care.  The Plan denied your request. The Plan says the enrollee does 
not meet Medicare guidelines because no longer requires skilled services on a daily inpatient basis and the 
continuation of SNF is not medically necessary.  
 
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 pre-approve 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 26, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0242U billed for January 24, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 0242U is 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. 
 
In this case, the CPT Code Manual definition of code 0242U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene 
copy number amplifications, and gene rearrangements. 
 
We find that CPT code 0242U is not supported in the medical record. Specifically there is no documentation of 
the testing for the billed date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0242U billed for January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service October 12, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says there is a more appropriate code that should be used. 
 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 file shows that panel testing was billed using multiple codes, including 81225, 81226, 81227, 81240, 
81241, and 81328. We find that the panel testing was not billed with a single code as required. 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 the lab testing billed for date of service October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service January 13, 
2023. 
 
You asked the Plan to pay for procedure code 88305. You say that this test was performed by a licensed 
pathologist and should be paid. The Plan denied your request. The Plan says this claim was submitted with a 
billing error. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that manifestation codes have a "code first" note and should be sequenced after an appropriate 
etiology code.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88305 have not been met. Specifically, this claim was submitted with diagnosis 
codes R84.6, I31.9 and I31.4. However, code I31.4 has a Code First note indicating that this code should be 
preceded with an underlying cause. No underlying cause was reported for this diagnosis. Therefore, we decided 
that the Plan does not have to pay for procedure code 88305 billed for date of service January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
December 29, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve transcatheter aortic valve replacement (TAVR) (33999). 
 
You asked the Plan to pre-approve TAVR. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development 
(CED) with certain conditions. 
 
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 TAVR. Our reviewer says that the 
services are medically necessary. Our physician reviewer found there are no medical treatments for any severe, 
symptomatic valvular heart disease in general and now available trans-catheter valve replacement is the only 
alternative for the right individual and in the right medical centers, which appear to be the case in 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 TAVR have been met. Therefore, we decided that the Plan has to pre-approve 
transcatheter aortic valve replacement (TAVR) (33999).  
 
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 (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
the enrollee has a diagnosis of COPD, although there are no pulmonary function tests to assess severity. The 
enrollee was hospitalized in 2022. A single arterial blood gas (ABG) was consistent with acute hypercarbic 
respiratory failure. There is no ABG done while stable to document chronic hypercarbic respiratory failure. If 
that is present, the enrollee may benefit from BiPAP with average volume-assured pressure support (AVAPS) 
during sleep as an outpatient. The record does not document that this has been tried and failed as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
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 (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 17, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 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 does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting to reconsider the claim for 
payment. The Plan denied your request. The Plan says the services are not authorized because Timothy Burns 
is a non-provider who does not work with the enrollee's health Plan. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an appendectomy at an outpatient level of care (44950, 
44970, 44960). 
 
You asked the Plan to pre-approve an appendectomy at an outpatient level of care. You say that you want the 
Plan to approve the services. The Plan denied your request. The Plan says this is an inpatient only procedure 
and cannot be approved as outpatient.  
The Plan must follow Medicare rules. Medicare rules say that the services designated to be inpatient only 
services are not appropriate to be furnished in a hospital outpatient department. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an appendectomy at an outpatient level of care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an appendectomy at an outpatient level of care (44950, 44970, 44960).
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 enrollee is at high risk for medical 
complications and needs a specialized team that will continue to monitor and react to the enrollee's changing 
medical needs that arise. The Plan denied your request. The Plan says they will continue to cover acute level 
care at the current hospital. 
 
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 receiving acute care services. At this time the enrollee can continue to 
receive services in the current acute care facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee still meets the 
criteria for inpatient services and electroconvulsion therapy. The Plan denied your request. The Plan says based 
on Medicare guidelines, the request for a continued stay at the psychiatric inpatient hospitalization level of care 
is not approved. 
 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 continued inpatient psychiatric care. 
Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. 
Our physician reviewer found it is not expected this enrollee will improve in a reasonable period of time as 
they do not have suicidal or homicidal ideation, auditory or visual hallucinations. The enrollee was compliant 
with treatment while not showing any acute threats to safety. Our reviewer also found that it does not appear 
medically necessary and reasonable 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 continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64633, 64634 x 2). 
 
You asked the Plan to pre-approve the RFA. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an initial thermal radiofrequency (RFA) of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and 
necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic medial 
branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary 
(index) pain. 
 
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 RFA. Our reviewer says that the 
requested RFA are not medically necessary. Our physician reviewer found the provided documentation does 
not indicate the results of two sets of diagnostic thoracic medical branch blocks (MBBs) submitted for review. 
The reviewer also found there is a utilization limit of two levels bilaterally per session of RFA. Therefore, the reviewer found that the requested RFA are not medically reasonable and 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64633, 64634 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy provided on October 06, 2022. 
 
You asked the Plan to pay for the cystourethroscopy. You say that the service not on the authorization was 
medically necessary. 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 cystourethroscopy 
provided on October 06, 2022.